{"id":859,"date":"2024-06-11T19:23:00","date_gmt":"2024-06-11T19:23:00","guid":{"rendered":"https:\/\/www.nepvneuro.com\/?page_id=859"},"modified":"2024-06-11T19:23:01","modified_gmt":"2024-06-11T19:23:01","slug":"payments","status":"publish","type":"page","link":"https:\/\/www.nepvneuro.com\/?page_id=859","title":{"rendered":"Payments"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;3.0.100&#8243; background_image=&#8221;http:\/\/www.nepvneuro.com\/wp-content\/uploads\/2018\/12\/what-is-Neuropsychology.jpg&#8221; parallax=&#8221;on&#8221;][et_pb_row _builder_version=&#8221;3.0.48&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.0.47&#8243; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221;][et_pb_divider show_divider=&#8221;off&#8221; height=&#8221;100px&#8221; _builder_version=&#8221;3.2&#8243;][\/et_pb_divider][et_pb_text _builder_version=&#8221;3.0.100&#8243; text_font=&#8221;|700|||||||&#8221; text_font_size=&#8221;50px&#8221; text_text_shadow_style=&#8221;preset1&#8243; background_layout=&#8221;dark&#8221;]<\/p>\n<p>Payments<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;3.6&#8243; parallax=&#8221;on&#8221;][et_pb_row _builder_version=&#8221;3.0.48&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.0.47&#8243; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221;][et_pb_text _builder_version=&#8221;3.0.100&#8243; text_font_size=&#8221;18px&#8221; text_line_height=&#8221;1.8em&#8221;][\/et_pb_text][wpforms_selector form_id=&#8221;864&#8243; _builder_version=&#8221;3.6&#8243; show_title=&#8221;on&#8221;][\/wpforms_selector][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Payments<div class=\"et_pb_module wpforms_selector wpforms_selector_0\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t<style id=\"wpforms-css-vars-864\">\n\t\t\t\t#wpforms-864 {\n\t\t\t\t\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-square wpforms-render-modern\" id=\"wpforms-864\"><form id=\"wpforms-form-864\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"864\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F859\" data-token=\"59dd65071cf43800f075997679f6e9ca\" data-token-time=\"1791905904\"><div class=\"wpforms-head-container\"><div class=\"wpforms-title\">Patient Bill Pay<\/div><\/div><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-864-field_41-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"41\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-864-field_41\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][41][first]\" aria-errormessage=\"wpforms-864-field_41-error\" required><label for=\"wpforms-864-field_41\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-864-field_41-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][41][last]\" aria-errormessage=\"wpforms-864-field_41-last-error\" required><label for=\"wpforms-864-field_41-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-864-field_42-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-864-field_42\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-864-field_42\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][42]\" spellcheck=\"false\" aria-errormessage=\"wpforms-864-field_42-error\" required><\/div><div id=\"wpforms-864-field_3-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-864-field_3\">Phone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-864-field_3\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][3]\" aria-label=\"Phone Number\" aria-errormessage=\"wpforms-864-field_3-error\" required><\/div><div id=\"wpforms-864-field_39-container\" class=\"wpforms-field wpforms-field-payment-select wpforms-field-select-style-classic\" data-field-type=\"payment-select\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-864-field_39\">Reason for Payment <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-864-field_39\" class=\"wpforms-payment-price wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][39]\" required=\"required\"><option value=\"1\" data-amount=\"0.00\" >Co-Pay<\/option><option value=\"2\" data-amount=\"0.00\" >Outstanding Balance<\/option><option value=\"3\" data-amount=\"0.00\" >Documentation Fee<\/option><option value=\"4\" data-amount=\"0.00\" >No Show\/Late Cancel Fee<\/option><option value=\"5\" data-amount=\"0.00\" >Other<\/option><\/select><\/div><div id=\"wpforms-864-field_32-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-864-field_32\">Other<\/label><input type=\"text\" id=\"wpforms-864-field_32\" class=\"wpforms-field-small\" name=\"wpforms[fields][32]\" aria-errormessage=\"wpforms-864-field_32-error\" ><\/div><div id=\"wpforms-864-field_43-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-864-field_43\">Patient ID<\/label><input type=\"text\" id=\"wpforms-864-field_43\" class=\"wpforms-field-small\" name=\"wpforms[fields][43]\" aria-errormessage=\"wpforms-864-field_43-error\" ><\/div><div id=\"wpforms-864-field_33-container\" class=\"wpforms-field wpforms-field-square\" data-field-type=\"square\" data-field-id=\"33\"><label class=\"wpforms-field-label\">Square <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-square-number\"><div id=\"wpforms-864-field_33\" class=\"wpforms-field-square-cardnumber wpforms-field-required\" aria-errormessage=\"wpforms-864-field_33-error\" data-required=\"required\"><!-- Square credit card will be inserted here. --><\/div><input\n\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\tclass=\"wpforms-square-credit-card-hidden-input\"\n\t\t\t\t\t\tname=\"wpforms[square-credit-card-hidden-input-864]\"\n\t\t\t\t\t\tid=\"wpforms-square-credit-card-hidden-input-864\"\n\t\t\t\t\t\tstyle=\"display: none;\" disabled><label  class=\"wpforms-field-sublabel after\">Card<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-square-name\"><input type=\"text\" id=\"wpforms-864-field_33-cardname\" class=\"wpforms-field-square-cardname wpforms-field-required\" name=\"wpforms[fields][33][cardname]\" aria-errormessage=\"wpforms-864-field_33-cardname-error\" required><label  class=\"wpforms-field-sublabel after\">Name on Card<\/label><\/div><\/div><\/div><div id=\"wpforms-864-field_34-container\" class=\"wpforms-field wpforms-field-payment-single\" data-field-type=\"payment-single\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-864-field_34\">Payment Amount (USD) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-864-field_34\" class=\"wpforms-field-small wpforms-field-required wpforms-payment-user-input wpforms-payment-price\" data-rule-currency=\"[&quot;$&quot;,false]\" data-rule-required-minimum-price=\"0.00\" data-rule-required-positive-number=\"1\" name=\"wpforms[fields][34]\" aria-errormessage=\"wpforms-864-field_34-error\"><\/div><div id=\"wpforms-864-field_37-container\" class=\"wpforms-field wpforms-field-signature\" data-field-type=\"signature\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-864-field_37\">Signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-864-field_37\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][37]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-864-field_37-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-medium\" data-input-method=\"draw\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-864-field_37-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><div id=\"wpforms-864-field_38-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"38\"><label class=\"wpforms-field-label\" 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