MIT Medical Department Payment Page

Bold = required
Payment Details

Statement Number
Responsible Party
Total Amount $	$
Description	MIT Medical Payment
Cardholder Billing Information
First/Last Name
Street Address 1
Street Address 2
City/State/Postal Code City/Province/Postal Code City/Province/Postal Code
Country
Phone Number	(nnn-nnn-nnnn)
Email Address	For Email confirmation

Patient payments are applied to oldest balances first.

For help with billing questions, call (617) 258-5336. Hours M-F 8:30am – 3:30 pm