Payments - Providence Healthcare Group, Inc.

Please use the form below to make your payment.

Payment Method

ACH Payment Details

Name of Business

Name of person paying with ACH

Title of person paying with ACH

Business Address

Street Address Address Line 2 City State ZIP Code

Invoice Number

Amount to be Paid

Name of Bank

Routing Number

Account Number

Consent(Required)

I agree to the ACH Terms and Conditions

I (we) hereby authorize PROVIDENCE HEALTHCARE GROUP, INC. to DEBIT my (our) account as directed in the fields on this form. I (we) acknowledge that the origination of ACH/Credit Card transaction to my (our) account must comply with the provisions of US law. This authorization is limited to this specific transaction and we do not store your payment information on file. The information provided on this form will be deleted after one time use.

Credit Card Payment Details

Date

Type of Credit Card

Name as it appears on card

Card Number

Expiration Date

Security Code (CCV)

Address credit card statement mail to

Street Address Address Line 2 City State ZIP Code

Invoice Number

Amount to be charged

Consent(Required)

I agree to the credit card terms and conditions

Hidden

Comments

This field is for validation purposes and should be left unchanged.