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The Oregon Clinic
PO Box 5036, Portland, OR 97208
(503) 963-2900
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Email
Patient ID or Account Number
Please make your payment at pay.instamed.com/orclinic
Medical Record Number
Guarantor ID
Guarantor First Name
Guarantor Last Name
First Name
Last Name
Middle
Date of Birth
Patient's date of birth (MM/DD/YYYY).
Phone Number
ZIP Code
Statement Number
Statement Date
Amount Due
Dynamic Field 1
Dynamic Field 2
Dynamic Field 3
Dynamic Field 4
ProviderAlias
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