Secure Billing Setup

Pay Online

Use this page to securely register a payment method for billing and account setup. Please do not include sensitive medical information in this form.

First name

Last name

Mobile phone

Card information is entered through the Authorize.net secure payment window. CMH-RI does not ask patients to enter full card numbers directly into this page.

https://js.authorize.net/v3/AcceptUI.jsscript>