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The University of Vermont Health Network Home Health & Hospice
1110 PRIM ROAD
Colchester, VT 05446
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Error Summary
Please, correctly fill out all required fields.
1. Patient Information
First Name
*
M.I.
Last Name
*
8-Digit Patient ID
*
HOME HEALTH & HOSPICE This number will appear on your invoice and should be 8 digits long.
Email Address
A receipt will be sent to this email address.
2. Payment Amount
Amount
HOME HEALTH & HOSPICE
3. Payment Method
Credit/Debit Card
Bank Account
Name on Card
*
Card Number
*
Expiration Date
*
MM
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YYYY
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2053
Security Code
*
Zip Code
*
Account Type
Checking
Savings
Routing Number
*
Account Number
*
Name On Check
Check Number
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