Community Health Connections, Inc.
Secure Payment Form
Payment Summary:
Payment Date:
12/02/24
Payment Amount:
Chart #:
Customer IP:
18.97.14.82
Credit Card Information:
Card Type:
Visa
MasterCard
American Express
Discover
Name as on Card:
Card Billing Address:
Card Billing Zipcode:
Card Number:
Card Expiration Date:
MMYY
Card ID (CVV2/CID) Number:
[
What is the CardID?
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Billing Information:
First Name:
Last Name:
Address:
Address Line 2(iIf not applicable, type N/A):
City:
State:
Zip:
Country:
Phone Number:
Email Address: