Secure Payment Form
Payment Schedule
If making a one time payment please select daily and number of payments to be "1"
Schedule (Please choose one)
Daily
Weekly
Biweekly
Monthly
Bimonthly
Quarterly
Biannually
Annually
Amount For Each Payment
Number of Payments
Start Date of Payments
Credit Card Information
Name as on Card
Card Billing Address
Card Billing Zip
Card Number
Card Expiration Date
CVV2/CID
Patient Information
Patient Account Number(s)
First Name
Last Name
Address
City
State
Zip
Phone Number
Email Address
Submit
If you have any questions, please contact our billing department at (716) 250-6401
