Harrison County Hospital

Account Details (This information appears on your statement.) Statement Date

Statement #

(Exactly as shown on your bill)

Amount Due $

Payment Amount $
Addressee Name

Additional Accounts

You may enter additional account numbers and amounts if paying more than one account.
	Statement #	Payment Amount ($)
	2.
	3.
	4.
	5.
	Total:

Credit / Debit Card Information Pay Amount $
Card Type
Name on Card
Card Number

1111222233334444

Expiration Date

Verification Code

What is this?

Credit Card Statement information:

Telephone
Address
City
State
Zip

Payment Terms Agreement I accept payment terms

Receipt Email Address

Your transaction receipt will be sent to the email address provided.

Captcha Verification

Code

(Enter the code from the image below)

(Please click the Process Payment button only ONCE.)

Verification Code

[close]

The Credit Card Association supports the Card Verification 2 Security Code (Vcode), a fraud mitigation feature.

Visa, MasterCard and Discover display a 3-digit code on the back of the card in the signature block at the end of the regular account number.

American Express displays a 4-digit code on the front of the card.

The Vcode value helps validate that ...
The customer has the actual card in his/her possession, and the card account is legitimate.

[close]