Home
Submit a Payment
Update Your Information
FAQ
Contact Us
Submit a Payment
You must have JavaScript enabled to use this page.
Important
: Please note that there is no additional fee for submitting a payment through our web site.
After making a payment, you will receive a confirmation number, please print or write this number down for future reference. If you do not receive a confirmation number, the payment was not processed.
Information being transmitted is secured for your protection.
Please look for the lock icon in your browser window.
Please note: Fields with an
*
must be completed for your information to be processed.
Patient Information
First Name
*
MI
Last Name
*
Account Number
*
(No dashes or spaces)
CHN
CHR
CHS
GWD
PSA
EPI
LAB
AHS
-
-
Payment Information
Amount
*
$
Credit Card Type
*
Visa
MasterCard
Discover
AMEX
Credit Card Number
*
(No dashes or spaces)
Expiration Date
*
01 - Jan
02 - Feb
03 - Mar
04 - Apr
05 - May
06 - Jun
07 - Jul
08 - Aug
09 - Sep
10 - Oct
11 - Nov
12 - Dec
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
Card Verification Value (CVV2)
*
What's this?
Cardholder's Name
*
(Exactly as it appears on the card)
Cardholder's Billing Address
Address 1
*
Address 2
City
*
State
*
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
DC - Washington
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
Zip
*
E-mail Address
Please email me a copy of my receipt.
Comments
(1000 Character Limit)