Please use this form to make a secure payment via Credit Card

Note: Fields marked with an asterisk (*) are required. This form will NOT process if they are not properly filled in.

Credit Card Information

Exact Name as it Appears on Credit Card* Please fill in the name on the credit card.
Address* Please supply address.
Address 2
City*
State/Province* Please supply state.
Zip/Postal Code* Invalid format.
Phone A value is required.

MPCS Account Information

Name on Credit Card is the same as the Account
Name on Credit Card is different from the Account
Name on MPCS Account for which Payment is Being Made*
MPCS Account Number
Address
Address 2
City
State/Province
Zip/Postal Code
10 Digit Phone#*
(includes area code)

PAYMENT METHOD

Amount being Paid* A value is required. Invalid format.
Credit/Debit Card Type*
Credit/Debit Card Number* A value is required.
3 Digit Security Code on
back of Credit Card*
3 digits require number of characters not met.
Name of Bank which
Issued Credit/Debit Card
A value is required. Invalid format.
Expiration Date*

Please print this page for your records before clicking on the Submit Payment button. Your payment will appear as "Medical and Professional" on your credit/debit card statement. We DO NOT mail receipts.

Please type the characters seen below in order to allow this form to process. If you have difficulty reading the characters, click on the image and one which is easier to read will appear.


Secure site - information sent via this form is secure
Please click submit button only once.
 
This is an attempt to collect a debt and any information obtained will be used for that purpose. This notice is from a debt collector.  
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Medical and Profesional Collection Services, Your Accounts Receivable Partner