Payment Arrangement by credit/debit card

Required fields are in red
Name and Address Information
First Name: M.I.  Last Name:
Address1: Address2:

State:     Zip:
Home Ph#: () - Work Ph #: () -
Account Information
Balance Owed To:
Account #:
Account # Type:

Your Card Information

First Name:
M.I.  Last Name: 
Card #: --- Security Code:
What is this?
Exp Date: / Card Type:
Payment Data
Method 1: Single payment of $ to be processed on
Method 2: Multiple Payments: Please specify up to ten payments below:
Amount Processing Date
After clicking the “Submit Information” button, you will see a printable receipt page. Please print and save for your records.

If you provide an e-mail address in the box below, you will receive a confirmation e-mail of this transaction.

My e-mail address is:

Please note, Med-Plan does not recommend using a work-related e-mail address for this purpose.

The confirmation e-mail will arrive via a “” email address. Please adjust your spam filter if necessary.

Thank you for utilizing