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Counseling Associates of Central Iowa PC

Secure Payment Form

  
Payment Amount

Total amount for all accounts being paid.

Account Number

If more than one account is being paid, please list all account numbers and amount for each account.

Patient Name

If more than one account is being paid, please list all patient names.

Phone Number

Please enter your phone number if we should have any questions. Thank you for your payment.

Name as on Card
Card Number
Card Expiration Date
CVV2/CID