Pay A Bill Form

Online Bill Payment Service

For your convenience, TriValley Primary Care offers a secure online method to pay a bill. Note: You will need to refer to a TriValley billing statement as you complete this form. Please complete the form below and submit.

(You may always pay a bill at a TriValley office.)

Please note: Only Visa, MasterCard and Discover cards are accepted. Other cards such as American Express and Diners Club are not accepted.

Valid information must be provided in all fields. Please click on [?] for help as needed.

Please enter the information for the person receiving the TriValley billing statement in this section:

Patient Information
Name:	[?]
Address: (City, State, Zip)	[?]
Date of Birth: (mm/dd/yyyy)	[?]
Telephone: (xxx-xxx-xxxx)	[?]
Patient Account #:	[?]

Please enter the information for the Credit Cardholder making the payment in this section:

Credit Card Information
First Name:	[?]
Last Name: (As appears on credit card. May be separate from patient name.)	[?]
Zip Code of Cardholder:	[?]
Amount:	(xxx.xx format)
Credit Card #:
Exp Date: (MMYY)
CVV2: (3 digit code on back of card)
E-mail Address:	[?]

NOTE: Please click submit button 1 time. Clicking more than once will result in multiple charges to your card. Expect a brief delay while your transaction is being processed.

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Pay A Bill Form

Online Bill Payment Service

Patient Information

Credit Card Information