Pay Online

Make A Payment

MAKE A ONE TIME PAYMENT KEEP CARD ON FILE FOR PAYMENTS

Paying online is a quick and easy way to address your bill. Please note that this is a separate system from CARE Counseling’s Electronic Health Records and you will not receive an email confirmation of payment and your records will be updated within 24 to 48 hours.

If you have any questions please don’t hesitate to contact Thera-PAY, our billing provider, at 218-301-3164 or visit www.thera-PAY.co

CARD TO BE KEPT ON FILE REQUEST

CARD *

EXP. DATE *

CVV *

NAME ON CARD *

First

Last

CARDHOLDER EMAIL *

CARDHOLDER PHONE *

CARDHOLDER ADDRESS *

Address Line 1

Address Line 2

City

State

Zip Code

Date Of Birth *//

IS THE CARDHOLDER DIFFERENT?*

Client Name *

First

Last

Client Date Of Birth *//

Client Email *

Client Phone

Client Address

Address Line 1

Address Line 2

City

State

Zip Code

NOTES (Client Relationship, When to Charge Card, etc.)

Payment Authorization *

I agree and authorize that each Care Counseling visit/session incurs a recurring charge of $100.00 or the known co-pay amount, as well as the full balance on my account to cover the co-pay or deductible the client is responsible for.

One Time Payment

Payment Amount *

CARDHOLDER EMAIL *

CARDHOLDER PHONE *

CARDHOLDER ADDRESS *

Address Line 1

Address Line 2

City

State

Zip Code

Date Of Birth *//

IS THE CARDHOLDER DIFFERENT?*

Client Name *

First

Last

Client Date Of Birth *//

Client Email *

Client Address

Address Line 1

Address Line 2

City

State

Zip Code

Client Phone

NOTES (DATE OF SERVICE, CLIENT RELATIONSHIP, ETC)

Credit Card *

Card

Name on Card

Make A Payment

CARD TO BE KEPT ON FILE REQUEST

One Time Payment

Click Here to view our financial agreement

Click Here to view information about Good Faith Estimate

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