Major Health Partners
Secure Payment Form
Account Information:
Payment Date:
11/03/24
Account Number(s):
When paying multiple accounts, please enter account numbers separated by commas
Payment Note:
Payment Amount:
Phone Number:
Email Receipt To:
Credit Card Information:
Card Type:
Visa
MasterCard
American Express
Discover
Name as on Card:
Card Billing Address:
Card Billing Zipcode:
Card Number:
Card Expiration Date:
MMYY
Card ID (CVV2/CID) Number:
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What is the Card ID?
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