Online Payments

Enter your patient and billing details below to process a payment.

 

Rehab Patient Information: (*denotes required field)

 

Name:*

Patient Name:*

Email:*

Confirm Email:*

Phone:*

Patient Account Number
(from statement):*

Comments:

 


Billing Information:

Billing information is the same as patient information above

Enter your name and address as they appear on your credit card or bank account statement.

 

Card Holder Name:*

Address:*

City*, State*, ZIP*:

   

Phone:

 


Payment Information:

 

Payment Method:

Is this a recurring / repeating payment?

Payment
Amount:*

$
Minimum recurring online payment is $25.00.

Card Number:*

Expiration Date:*

/

Verification Code:*


Answer the math problem to submit:

What does equal?