Payment Arrangement by credit/debit card
Required fields are in red
Name and Address Information
First Name:
M.I.
Last Name:
Address1:
Address2:
City:
State:
Please Select One
ALASKA
ALABAMA
ARKANSAS
ARIZONA
CALIFORNIA
COLORADO
CONNECTICUT
DC
DELAWARE
FLORIDA
GEORGIA
GUAM
HAWAII
IOWA
IDAHO
ILLINOIS
INDIANA
KANSAS
KENTUCKY
LOUISIANA
MASSACHUSETTS
MARYLAND
MAINE
MICHIGAN
MINNESOTA
MISSOURI
MISSISSIPPI
MONTANA
NORTH CAROLINA
NORTH DAKOTA
NEBRASKA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEVADA
NEW YORK
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VIRGINIA
VERMONT
WASHINGTON
WISCONSIN
WEST VIRGINIA
WYOMING
OTHER
Zip:
Home Ph#:
(
)
-
Work Ph #:
(
)
-
Account Information
Balance Owed To:
Account #:
Account # Type:
Med-Plan Account # (found on our statements)
Provider Account #
Last 4 Digits of your Social Security Number
Your Card Information
First Name:
M.I.
Last Name:
Card #:
-
-
-
Security Code:
What is this?
Exp Date:
Month
01
02
03
04
05
06
07
08
09
10
11
12
/
Year
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Card Type:
Visa
Mastercard
Debit Card
Payment Data
Method 1:
Single payment of $
to be processed on
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Method 2:
Multiple Payments: Please specify up to ten payments below:
Amount
Processing Date
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Comments
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 “MedPlanWebReceipt.com” email address. Please adjust your spam filter if necessary.
Thank you for utilizing MedPlanPayments.com.