payment.natera.com Open in urlscan Pro
162.242.180.188  Public Scan

Form analysis
5 forms found in the DOM

<form id="guestPayStepOne" novalidate="novalidate">
  <div class="form-group mb-4">
    <!--<label class="bmd-label-floating idLbl">-->
    <!--Enter Statement Reference ID / Visit Reference ID-->
    <!--</label>-->
    <input type="text" id="id" name="id" class="form-control id" placeholder="Enter case number">
    <span class="help-block white-text"></span>
  </div>
  <div class="form-group backend-error backendErrorS">
  </div>
  <div class="form-group statement-date-type-wrapper mb-4">
    <div class="radio radio-select">
      <label class="fnt-visible">
        <input type="radio" name="statementDateType" id="sdtdob" value="dob" checked=""> Date of birth </label>
    </div>
    <div class="radio radio-select">
      <label class="fnt-visible">
        <input type="radio" name="statementDateType" id="sdtdos" value="dos"> Date of service </label>
    </div>
  </div>
  <div class="form-group mb-4">
    <!--<label class="bmd-label-floating dateLbl">-->
    <!--Enter Statement Date / Date of Service-->
    <!--</label>-->
    <input type="text" id="datepickerOne" name="datepickerOne" class="form-control date hasDatepicker" placeholder="Date of birth">
    <span class="help-block white-text">MM/DD/YYYY</span>
  </div>
  <div class="form-group backend-error backendErrorD">
  </div>
  <div class="form-group mb-3">
    <!--<label class="bmd-label-floating">-->
    <!--Enter your Email-->
    <!--</label>-->
    <input type="text" id="payerEmail" name="payerEmail" class="form-control payerEmail" placeholder="Enter email">
    <span class="help-block white-text"></span>
  </div>
</form>

---

<form id="paymentPlanInitFrom">
  <div class="form-group form-md-line-input">
    <span class="dollar">$</span>
    <label>Enter initial amount </label>
    <input type="text" class="form-control" name="planInitValue" id="planInitValue" required="">
    <span class="help-block white-text">
    </span>
    <div class="small-text"> (Initial payment amount must be in between $<span class="minInit"></span> and $<span class="maxInit"></span> for this statement) </div>
  </div>
</form>

---

<form id="signUpForm" role="form">
  <div class="form-group">
    <label class="bmd-label-floating" for="signUpEmail"> Enter user email </label>
    <input id="signUpEmail" name="signUpEmail" type="email" class="form-control" required="">
    <span class="help-block white-text"></span>
  </div>
  <div class="form-group">
    <label class="bmd-label-floating" for="signUpPhoneNumber"> Enter mobile phone number </label>
    <input id="signUpPhoneNumber" name="signUpPhoneNumber" type="text" class="form-control" required="">
    <span class="help-block white-text">1XXXXXXXXXX</span>
  </div>
  <div class="form-group">
    <label class="bmd-label-floating"> Enter patient date of birth </label>
    <input type="text" id="datepickerTwo" name="datepickerTwo" class="form-control date hasDatepicker" required="">
    <span class="help-block white-text">MM/DD/YYYY</span>
  </div>
</form>

---

<form id="payment-form">
  <div class="form-group bmd-form-group is-filled row col-12 mx-0">
    <div id="cardNumberElement" class="col-12"></div>
    <div id="cardExpiryElement" class="col-5"></div>
    <div id="cardCvcElement" class="col-5 offset-2"></div>
    <!-- Used to display Element errors. -->
    <div id="stripe-card-error" role="alert" style="display:none">All fields must be filled to proceed</div>
  </div>
</form>

---

<form id="downloadVisitForm" novalidate="novalidate">
  <div class="form-group">
    <label class="bmd-label date-lbl"> Date of birth </label>
    <input type="text" id="datepickerDOB" name="datepickerDOB" class="form-control date hasDatepicker" required="">
    <span class="help-block white-text">MM/DD/YYYY</span>
  </div>
</form>

---

Text Content

 * Payment
 * FAQ
 * Contact us


WHAT IS AN EXPLANATION OF BENEFITS (EOB)?



--------------------------------------------------------------------------------


PAY YOUR STATEMENT NOW

Date of birth
Date of service
MM/DD/YYYY




PAY YOUR STATEMENT NOW

Case Number:

Statement Date:

Statement Amount:

Selected Pay Amount:




SELECT YOUR PAYMENT OPTION

Case Number:

Statement Date:

Statement Amount:

Selected Pay Amount:

Full payment
Payment plan
$ Enter initial amount
(Initial payment amount must be in between $ and $ for this statement)
Remaining balance applied to payment plans: $

SIGN UP

Sign up to view all your statements, visit information, all past transactions
and payment plan details

Enter user email
Enter mobile phone number 1XXXXXXXXXX
Enter patient date of birth MM/DD/YYYY
Contact Admin


ENTER CARD DETAILS

All fields must be filled to proceed


SELECT PLAN DURATION

Case Number:

Statement Date:

Statement Amount:

Selected Pay Amount:

Select Duration (in months) 1
Note:
Based on selected duration initial amount and carry forward amount to the plan
might slightly change.
Monthly installment payments will be automatically processed from your card.
Initial amount: $
Amount carry forward to the installments: $
Monthly installment amount: $
By submitting, I agree to the Terms of Service and Privacy Policy.
   
 * Proceed
   
   

 * Find my statement Proceed Pay $ Initiate payment plan Proceed Cancel

TERMS OF SERVICE AND PRIVACY POLICY.

×

Close

SELECT YOUR OPTION TO PROCEED

×

Please click "SUMMARY & PAYMENT OPTIONS" to proceed with payments

Summary & Payment Options


Please enter patient date of birth and click on "DOWNLOAD STATEMENT" button

Date of birth MM/DD/YYYY

PLEASE NOTE THAT ...

 * Click to view/download the invoice mailed on to the address on file for this
   case.

Download statement

×
Payment Status

PAYMENT RECEIPT

Transaction Reference ID

Transaction Date

Card Number
....
Transaction Amount


--------------------------------------------------------------------------------

Details
Reference ID

Previous Due

Transaction Amount

Current Due


--------------------------------------------------------------------------------

Please note that it will take 3 - 5 business days for the payment to reflect on
the case

Print


SELECT PLAN DURATION

Case Number:

Statement Date:

Statement Amount:

Selected Pay Amount:

Select Duration (in months) 1

--------------------------------------------------------------------------------

Note: Based on selected duration initial amount and carry forward amount to the
plan might slightly change.
Initial amount: $
Amount carry forward to the installments: $
Monthly installment amount: $
Initiate payment plan Cancel

PAYMENT PLAN DETAILS

×
Success: Payment plan initiated successfully!
Statement/ Case/ Visit ID

Plan ID

Plan Status

Initiated Date

Duration
Months
Last Installment Date

Installment Amount
$

--------------------------------------------------------------------------------

Total Amount
$
Initial Amount
$
Payment Plan Amount
$
Note: Monthly installment payments will be automatically processed from your
card.
Print


1