This is a simple way to make your payment. You can do it anytime, day or night, from the comfort of your home or office. Patient InformationPatient Name(Required) First Last Patient Account Number(Exactly as shown on your statement) Payment Amount(Required) Credit / Debit Card InformationCredit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Month010203040506070809101112 Month Expiration Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Year Expiration Date Security Code Cardholder Name Billing Address(Required) Street Address City State (Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Payment Terms AgreementConsent(Required) I agree to authorize Rehabilitation & Performance Institute, PSC. to process my debit/credit card for the amount shown above and apply that amount to my Rehabilitation & Performance Institute account.Receipt Email Address(Required)Your transaction receipt will be sent to the email address provided. CommentsThis field is for validation purposes and should be left unchanged. Δ
