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Patient Portal and Premium Payments Portal: Request Data Fields

FieldGET POSTSSO Assertion AttributesSSO relayState ParametersRelayState EncryptionSSO NVPFormatRequired?MinMaxCommentsUsage
id ✓✓ANY1100InstaMed Payment ID (Alias) assigned during implementation.ALL
accountHolderEmailAddress ✓✓✓✓✓ANN1200Consult your Implementations Manager for specific requirements that may apply.ALL
userID✓✓✓✓✓ANY1200Consumer user ID. Unique field that identify the consumerALL
accountNumber ✓✓✓✓✓ANN1100The account number (with dashes “–’’) for the account from which a check is drawn.ALL
routingNumber ✓✓✓✓✓ANN99The routing number for the bank from which a check is drawn.ALL
checkNumber ✓✓✓✓✓ANN150The number of the check.ALL
checkState ✓✓✓✓✓ANN22Account holder's address state.ALL
accountType ✓✓✓✓✓ANN18The type of account from which a check is drawn. "Checking," "Savings."ALL
additionalInfo2 ✓✓✓✓✓ANN1100User-defined fields to be captured with the payment transaction.ALL
additionalInfo3 ✓✓✓✓✓ANN1100See AdditionalInfo2 comments.ALL
additionalInfo4 ✓✓✓✓✓ANN1100See AdditionalInfo2 comments.ALL
additionalInfo5 ✓✓✓✓✓ANN1100See AdditionalInfo2 comments.ALL
additionalInfo6 ✓✓✓✓✓ANN1100See AdditionalInfo2 comments.ALL
amount ✓✓✓✓DECN110The amount of money being authorized or charged to a credit or debit card, or the amount for which a check is written. Must be greater than 0.ALL
billingAddress1 ✓✓✓✓✓ANN155The primary street address associated with the accountholder or guarantor.ALL
billingAddress2 ✓✓✓✓✓ANN155The street address second line associated with the accountholder or guarantor.ALL
billingCity ✓✓✓✓✓ANN130The city associated with the accountholder or guarantor.ALL
billingState ✓✓✓✓✓ANN12The state associated with the accountholder or guarantor.ALL
billingZip ✓✓✓✓✓ANN57The postal code associated with the accountholder or guarantor.ALL
billingCountry ✓✓✓✓✓ANN150See Country Codes.ALL
billingAreaCode ✓✓✓✓✓ANN13Area code for the account holder (i.e., billing) phone number.ALL
billingPhoneNumber ✓✓✓✓✓ANN18Account holder (i.e., billing) phone number.ALL
cardNumber ✓✓✓✓✓ANN116Credit card number with no spaces or hyphens. Users may also key or swipe this information on the Patient Payments or Payment Plans page.ALL
cardExpDate ✓✓✓✓✓DTN44This is the credit card’s expiration date, and it must be a valid date. Should be one of the following: MM-YY or MM/YY.ALL
cardHolderName ✓✓✓✓✓ANN1121Conditionally applicable based on outlet configuration. Consult your Implementations Manager for whether these fields are supported for your implementation.ALL
cardType ✓✓✓✓✓ANN110Supported values: "VISA,” "MASTERCARD," "AMEX,” "DISCOVER."ALL
checkHolderFirstName ✓✓✓✓✓ANN150Conditionally applicable based on outlet configuration. Consult your Implementations Manager for whether these fields are supported for your implementation.ALL
checkHolderLastName ✓✓✓✓✓ANN150Conditionally applicable based on outlet configuration. Consult your Implementations Manager for whether these fields are supported for your implementation.ALL
invoiceNumber ✓✓✓✓✓ANN150User-defined field to be captured with the payment transaction. Also referred to as AdditionalInfo1.ALL
patientAddress1✓✓✓✓✓ANN155Street address line 1 for the patient, which may be different than the guarantor address.ALL
(consumerAddress1)
patientAddress2 ✓✓✓✓✓ANN155Street address line 2 for the patient, which may be different than the guarantor address.ALL
(consumerAddress2)
patientCity ✓✓✓✓✓ANN130City for the patient, which may be different than the guarantor address.ALL
(consumerCity)
PatientState ✓✓✓✓✓ANN22State for the patient, which may be different than the guarantor address.ALL
(consumerState)
patientZip1 ✓✓✓✓✓ANN55Postal code for the patient, which may be different than the guarantor address.ALL
(consumerZip)
patientCountry ✓✓✓✓✓ANN150See Country Codes.ALL
(consumerCountry)
patientEmailAddress ✓✓✓✓✓ANN1200ALL
(consumerEmailAddress)
patientFirstName ✓✓✓✓✓ANN125ALL
(consumerFirstName)
patientBirthDate ✓✓✓✓✓DTN88ALL
(consumerDOB)
patientID ✓✓✓✓✓ANN150A unique identifier for the patient, which is typically sourced from the Patient Accounting System.ALL
(consumerID)
patientLastName ✓✓✓✓✓ANN135ALL
(consumerLastName)
patientMedicalRecordNumber ✓✓✓✓✓ANN1100ALL
(consumerMedicalRecordNumber)
patientMiddleName ✓✓✓✓✓ANN125ALL
(consumerMiddleName)
patientAreaCode ✓✓✓✓✓ANN13ALL
patientPhoneNumber ✓✓✓✓✓ANN18ALL
patientServiceBeginDate ✓✓✓✓✓DTN1010ALL
(consumerServiceBeginDate)
patientServiceEndDate ✓✓✓✓✓DTN1010ALL
(consumerServiceEndDate)
transactionCode ✓✓✓✓✓ANN150Note : Please submit the Transaction Code rather than description. Consult your Implementations Manager to configure Transaction Codes on your account.ALL
consumerChargeLimit✓✓✓✓DECN110This is the default value for charge limit, consumer will be able to change it in UI.ALL
consumerEnrollinAutomaticPayment✓✓✓✓BN22Indicate to check the Enroll in Automatic paymentALL
saveCardOnFile✓✓✓✓BN22Indicate to check save payment method on fileALL

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