Use the form below to submit your payment online. "*" indicates required fields Date MM slash DD slash YYYY PATIENT/CLIENT INFORMATIONInvoice Number (as it appears on bill):Patient/Client ID (if known):Patient/Client Name (as it appears on bill):* First Last Description (brief description of services provided):Contact Name (if different than Patient/Client above): First Last Contact Email:* Contact Phone:*BILLING INFORMATIONBilling Name (as shown on credit card):* First Last Billing Address Street Address Address Line 2 City State 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 ZIP Code Billing Email:* Billing Phone:*Payment Amount:* Credit Card Information* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name Questions or Comments?If you have any questions, please call Care Synergy at 303-780-4600, email us at csar@caresynergynetwork.org, or use the area below.Consent* By clicking the "SUBMIT" button below, you are authorizing Pikes Peak Hospice & Palliative Care to charge your credit card the amount entered above and to process your data for the purposes of this form. We value your privacy. Read about our privacy practices for more information.NameThis field is for validation purposes and should be left unchanged.
