EC Make a Payment

Client (Provider) Name *

Practice / Company Name

Payment Amount *

How would you like to pay? *

Credit Card Type *

Credit Card Number *

Exp. Date (mm/yy) *

CVV2 * 🛈

Name as it appears on card *

Billing Street Address *

Billing ZIP *

Name of Financial Institution *

Account Type *

Transaction Date * +

Routing Number *

Account Number *

Name on Account *

Phone Number *

Would you like to receive an email receipt for this transaction? *

Please provide your email address *

NOTE: A receipt for this transaction will be sent to this email address after your payment has been processed.