Secure Payment Page for the

Village Pediatrics
Added Benefits Fee

Total Amount Due:

FAMILY INFORMATION

Family Last Name

Address

City, State, ZIP

Account Number (Preferred, but Optional)

ADDED BENEFITS FEE

Please use this page ONLY to pay your Added Benefits Fee.

Please note: This fee is a mandatory, per-child, yearly administrative fee.

After entering your demographic information along with the names and dates of birth for each of your children, please enter the amount due based upon below as of January 2025.

Early Bird Discount: $20 PER FAMILY if paid prior to 1/1/25 (please deduct this from your total manually)

Newborns up until age 1 $175/infant
Ages 1+: $250/child
Ages 18+ $175

FAMILY CAP IS $750

Payment Due No Later Than 2/1/2025

Late Fee after 2/1/2025

All other payments should be completed through our patient portal account at Village Pediatrics My Kids Chart Patient Portal.

**IMPORTANT: As HSA and FSA programs vary greatly, please check with your program administrator to determine if this Added Benefits Fee is HSA or FSA eligible**

Payment Info

Choose payment method

Payment details

Card Number

Expiration Date

Security Code (CVV)

Billing Info

First Name

Last Name

Address 1

Address 2

City

State

Zip/Postal Code

Country

Email Address

Phone #

lockSecure Payment Page for the

Village PediatricsAdded Benefits Fee