Payment Form

Please fill in the details below from your statement and choose your payment method, and click "Proceed" to complete your payment on the next screen.

Please note: we have been experiencing issues with certain HSA / FSA cards -
send us a message and we will call you back and process your payment for you.

Name *

ACCT # from Statement *

Amount to Pay *

Email Address (for your receipt) *

Phone Number *

Please choose your payment method *