Capitol City Rehab And Healthcare Center
Secure Payment Form
Billing Information
Patient Name
Street
City
State
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Phone
Email
Customer ID
Transaction Details
Make this a recurring transaction
Every
Day(s)
Week(s)
Month(s)
Year(s)
For a total of
payments
Order/Invoice
Invoice cannot exceed 190 characters
Amount
$
Payment Information
Credit Card
Check
Card Number
Change Card Number
MM
01
02
03
04
05
06
07
08
09
10
11
12
YY
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
CVV
i
CVV Is the 3 digit number on back of your Visa & MasterCard. On Amex it Is a 4 digit number in front of the card.
Account Type
Select One
Checking
Savings
Name on Account
Routing Number
i
Account Number
i
Change Acount Info
Process Payment
(
$
0.00
)
X