Bill Pay - CLINICA family health

Step 1 of 2 - Patient Information

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Clinica Account Number*
Payment Amount*
Patient Name*
Patient First Name Patient Last Name
Patient Date of Birth*

Cardholder Name*
Cardholder First Name Cardholder Last Name
Cardholder Address*
Street Address Address Line 2 City State ZIP Code
Cardholder Email*
Cardholder Phone*
Credit Card*

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Visa
Card Number Expiration Date Security Code Cardholder Name
Memo
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Name
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Special Open Enrollment Period: Coloradans can enroll in low-cost health insurance now through May 15. For more information, call 855-PLANS-4-YOU (855-752-6749).