Covenant Physician Partners
* State:
Arizona
Arkansas
California
Colorado
Delaware
Florida
Georgia
Hawaii
Illinois
Indiana
Maine
Maryland
New York
Pennsylvania
South Carolina
Tennessee
Texas
Wisconsin
The state is required.
* Select Group:
Ambulatory Surgical Centers (ASC/Facility)
Anesthesia Services
Pathology Services (Lab)
Physician Practice Services (Dr’s Office)
The group is required.
* Select Location:
The location is required.
* Account Number:
The account number is required.
The account number may not contain a credit card number.
Guarantor/Patient Name:
The guarantor/patient name may not contain a credit card number.
* Payment Amount:
The payment amount is required.
The payment amount is not valid.
The payment amount may not contain a credit card number.