Compass Health - Acceptiva

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Medical Records Invoice Payment

Thank you for choosing to pay your Medical Records invoice online. All contact information and payment information you enter is secure and confidential. You will be able to print a receipt at the end.

Payment Amount

Full Payment

Partial Payment

Total: $0.00

Invoice Number: *

Client Name: *

Is this a pre-payment for records? If so, records will be processed after payment is received.

Payer Information

First Name: *

Last Name: *

Agency Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Telephone:

Email: *

A receipt will be emailed to this address.

Comments / Notes:

If more than Three (3) Registrants add name and e-mail information here.

Your Payment Information

Name on Card:

Card Number:

Security Code:

Expiration Date: