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(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Expiration Month010203040506070809101112 Year Expiration Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Security Code Cardholder Name Billing Address(Required) Street Address City State (Required)AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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. CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ
