ONLINE PAYMENT FORM

We are now accepting payments online. The amount paid will be credited toward your account balance. To complete payment, please have in front of you:
-- Provider invoice
-- Patient account number (if you are not the patient, please have the patient's account number, not your own)
-- Patient information including address and phone number
-- Credit Card (MasterCard, Discover, Visa or American Express) or Bank Account Information
If you have questions concerning your account, please contact us at patinq@dmms.us, or call 302-283-3300.

Account Information

Patient Account Number

 
Patient Name

 
Provider Name or FEI Number

 

Your Information

Your Name

 

Email Address

 
 

Phone Number
(xxx-xxx-xxxx)

 
 
Your Street Address

 

City

 

State and Zip
     
 

Payment Information

Select Payment Type

Payment Amount
$
 
 
Question/Comment

 
Disclaimer and Terms of Use
Please Read the USER AGREEMENT Carefully Before Continuing

1. By using this website, you agree to pay the amount due as noted. If you have questions regarding your payment, please call the billing office at 302-283-3300. Customer Service Representatives are available Monday through Friday from 9:00am to 4:00pm

2. You understand and agree that the use of this web site to handle a payment does not alter or extend any payment deadlines. Thus, your failure to make any payment on time or other failure to meet any deadline will not be excused,

even if caused by any malfunction relating to this web site, and any applicable penalties, fines and interest levied or accruing as a result of such failure to pay on time or meet another deadline will apply.

3. In consideration of your use of this web site, you agree to provide true, accurate, and current information. If you provide any information that is untrue, inaccurate, or not current, or if DMMS, LLC has reasonable grounds to suspect

that such information is untrue, inaccurate, or not current, DMMS, LLC has the right to terminate your use of any services on this web site.

4. You understand and agree that DMMS, LLC reserves the right at any time and from time to time to modify or discontinue, temporarily or permanently, any services provided on this web site and any conditions of use with or without notice.

5. You understand and agree that the providers billing office, DMMS, LLC may, under certain circumstances and without prior notice, immediately terminate your access to this web site. Cause for immediate termination will include, but not be limited to,(a) breaches or violations of this User Agreement or other incorporated agreements or guidelines, (b) requests by law enforcement or other government agencies, (c) discontinuance of services or content modifications to this web site, (d) technical problems or errors,and (e) extended periods of inactivity.

6. DMMS, LLC makes no guarantees, promises, or warranties regarding the accuracy of information and data provided by any section in this web site. You agree and understand that the information and data on this web site are being provided 'as-is'

without warranty of any kind and that the information and data may be subject to errors and omissions. To the extent permitted by law, DMMS disclaims all warranties, including, without limitation, any implied warranties of merchantability, accuracy and

fitness for a particular purpose, and non-infringement. The user acknowledges and agrees DMMS nor any vendor or service relating in any way to our online efforts is or will be liable in any way whatsoever for the accuracy or validity of the information provided.

Use of this service to submit payment constitutes acknowledgment that DMMS and the processor of electronic payments assume no responsibility for data entered by service users.

7. This site is committed to protecting your privacy. Security measures for this site have been taken to protect against loss, misuse or alteration of the information you provide; and industry standard encryption methods are used to assure security. Nevertheless, it is crucial that, as a user, you protect against unauthorized access to your password and to your computer and that you always sign off when finished using a shared computer. Further, you should be aware that no system is impenetrable. Thus, it is your responsibility to diligently monitor your credit card statements, bank statements and similar personal information so as to discover and address as quickly as possible any misuse of your personal information.