Credit Card Risk Notification
Please be advised that New York State law requires us to notify you of the following when you choose to pay by a credit card for services:

1. Medical bills paid by credit card are no longer considered medical debt.
2. By paying with a credit card, patients are forgoing federal and state protections around medical debt.
3. Protections that patients must acknowledge forgoing include:
a. Prohibitions against wage garnishment and property liens
b. Prohibition against reporting medical debt to credit bureaus
c. Limitations on interest rates

By allowing or consenting to allow JRCHC to charge your credit card for payment, you acknowledge this credit card risk notification.

Patient Information

Account Number

Note: Your account number can be found at the top of your statement.

First Name

Last Name

Address

City

State

Zip

Card Holder Information

Same as Patient

First Name

Last Name

Address

City

State

Zip

Credit Card Information

Credit Card Number

Credit Card Expiration

Credit Card CVV

Payment Amount

I agree to pay the amount above according to the card issuer agreement

Terms & Services
Privacy Policy: Any and All required information submitted on the website is secure and will not be used for any other purposes other than intended.
Return/Refund Policy: All refunds/returns are handled by management which is reachable by contacting the customer service number listed. Please note that all refunds are at the sole discretion of Management. Member Service Phone Number: (716)-881-6191

Online Bill Pay

Patient Information

Card Holder Information

Credit Card Information