Patient Payment Form

Patient Name*
Patient Account Number
Patient Date of Birth
Contact Number*
Email Address*
Used for sending confirmation
Other Contact Numbers
Day: Evenings: Cell:
Current Address*
Is this a new address?
Credit Card Type*
- Visa
- MasterCard
- Discover
- American Exp
Name as it appears on credit card*
Credit Card Number*
Credit Card Expiration Date*
Security Code on Credit Card*
American Express cards have a four-digit code printed on the front side of the card above the number.

Discover, MasterCard, and Visa credit and debit cards have a three-digit card security code. The code is the final group of numbers printed on the back signature panel of the card.
Total to be charged $*
Mail Receipt?
- No
- Yes
Has Your Insurance Carrier Changed?*
- No
- Yes
Name of New Insurance Carrier*
Group Number*
Policy Number*
Is this your primary carrier?
- Yes
- No
Do you have more than one healthcare insurance carrier?*
- No
- Yes
Please list your secondary insurance carrier*
Group Number*
Policy Number*
Do you have a third insurance carrier?*
- No
- Yes
Please list your third insurance carrier*
Group Number*
Policy Number*

Dilley Allergy & Asthma Specialists, LLP
7835 W. Interstate 10
San Antonio, Texas 78230

Phone: 210.614.4405
Fax: 210.614.7892