Secure Payment Form

If making a one time payment please select daily and number of payments to be "1"
Schedule (Please choose one)
Total Amount
Number of Payments
Billing Amount
Start Date of Payments
Name as on Card
Card Billing Address
Card Billing Zip
Card Number
Card Expiration Date
CVV2/CID
Patient Account Number(s)
First Name
Last Name
Address
City
State
Zip
Phone Number
Email Address

If you have any questions, please contact our billing department at (716) 250-6401