Pay My Bill/Pagar Mi Cuenta - Nicasa Behavioral Health Services

Payment Amount/Cantidad del Pago *

ID Number/Número de Identifcación *

Name/Nombre y Apellido *

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Last

Date of Birth/Fecha de Nacimiento *

Address/Dirección *

Address Line 1

Address Line 2

City

State

Zip Code

Phone/Número de Teléfono *

Email/Correo Electrónico *

Terms of Use *

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By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.