PAYMENT ON ACCOUNT

- INDICATES REQUIRED FIELD

Payment Fields
Credit Card Number:
Expiration Date (MMYY):
Payment Amount:$
CVV2 Indicator:
CVV2:
Client Number:
Client Name:
Description:
PFH Location:
Billing Information
First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zip:
Country:
Phone:
Email:
(required for receipt)



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Preferred Family Healthcare staff members shall preserve the confidentiality of all consumers and consumer information in accordance with federal and state laws and regulations regarding confidentiality, including the federal regulations Confidentiality and Alcohol and Drug Abuse Client Records, 42 CFR Part 2 and HIPAA regulations.


All credit card payments are final and non-refundable