Make a Payment Account / Customer ID*Patient Name* First Last Facility Location*Alexandria, VAAlexandria (Outpatient), VAAnnandale, VA (MH)Atlanta, GAAtlantic, CA (MH)Austin (Outpatient), TXAustin, TX (OP MH)Austin, TX (RTC MH)Bellevue, WABellevue (Outpatient), WABeverly Hills, CABridgewater, NJBrentwood, CABrentwood, CA (II)Chicago / Glenview, ILChicago ED RTCChicago (Outpatient MH), ILChicago (Outpatient ED), ILChino Hills, CADallas, TXDallas (Outpatient), TXDanville, CADel Mar, CADel Mar (Outpatient), CADowney, CAEdmonds, WAFairfax, VA (RTC ED)Fairfax Station, VA (OP MH)Fairfax Station, VA (RTC MH)Fairfield, CT RTC (MH)Fairfield Adult, CTFremont, CAFresno, CAGlendale, CA (Outpatient)Greenwich, CTHamptons, NYHouston, TX (RTC ED)Houston, TX (Outpatient ED)Houston, TX (OP MH)La Habra, CALa Jolla, CALakewood, CALos Alamitos, CA (ED)Los Alamitos, CA (MH)McLean, VAMenlo Park, CAMira Mesa, CANew Haven, CT (ED)New Haven, CT (MH)Newport Beach, CA (Outpatient ED)Newport Beach, CA (OP MH)Orlando, FL (RTC ED)Orlando (Outpatient ED), FLOrlando, FL (OP MH)Palm Beach Gardens, FL (Outpatient ED)Palm Beach, FL (OP MH)Paramus, NJPinelands Recovery Center (Outpatient) - Medford, NJPinelands Recovery Center (RTC) - Medford, NJPleasanton (Outpatient), CAPortland, ORPortland, OR (MH)Rancho Palos Verdes, CASacramento, CA (ED)Sacramento, CA (MH)San Jacinto, CA (MH)Sherman Oaks (Outpatient), CASouthbay (Outpatient), CAStamford MH RTCSouthport, CT (Outpatient ED)Southport, CT (RTC ED)Tacoma, WATampa, FLTemecula, CA (Outpatient ED)Temecula, CA (OP MH)Thousand Oaks, CAVista, CAResilience in Recovery Workshop SeriesLong Beach, CAPacific Place, CAWellington, CTWhittier, CAWoodland Hills (Outpatient), CANotesName* First Last Email* Phone*Billing InformationAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Payment Amount* Enter the amount of payment to be made.