Account Details (This information appears on your statement.)






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


Checking Information
Sample Check
Amount to be paid

See above

See above

As it appears on check








Payment Terms Agreement
I agree to provide Lourdes Hospital with my Bank and Account information and hereby authorize Lourdes Hospital to debit my bank account for this transaction. I understand that when I authorize a payment to be made through this website, I am requesting an electronic transfer from my bank account. When making such a pre-authorized payment, Lourdes Hospital will make electronic transfers via the Automated Clearing House (ACH) system from my bank account in the amount I specify.

Cancellation If you made an ACH Debit transaction and wish to revoke or cancel this transaction you must call us at the number listed in the Contact Us section of this website.



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




Captcha Verification
(Enter the code from the image below)


 
(Please click the Process Payment button only ONCE.)
 
© 2025 RevSpring, Inc. All rights reserved