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)
Numbers only - no spaces

PAYMENT METHOD

Amount being Paid* A value is required. Invalid format.
Credit/Debit Card Type*
Credit/Debit Card Number* A value is required. Numbers only - no spaces
3 Digit Security Code on
back of Credit Card*
3 digits required
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.

click to print image

security code
Enter Security Code:

Secure site - information sent via this form is secure
Please click submit button only once. Entering the data and clicking submit will send the info to MPCS to begin the posting process.
 
This communication is from a debt collector. This is an attempt to collect a debt and any information obtained will be used for that purpose.