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Account Information

Account number

Memo

Payment Information

First name

Last name

Card number

Expiration date

Security code

Address 1

Address 2

City

State

Country

Zip

Zip plus 4

Email address

Phone number

Payment ($)

You are agreeing to pay $ plus a Fee of $ (%) for a Total of $.

Number of Payments: 0

Confirmation

Are you human?

I authorize Horizon Village Inc. to process the above payment of $. I also authorize Horizon Village Inc. to store this information in compliance with payment processing regulations and to charge the card listed above for future payments in accordance with their terms. I understand that to make any changes to this authorization I must contact Horizon Village Inc. prior to the payment date.

I authorize Horizon Village Inc. to process the payments as outlined in the payment schedule. I also authorize Horizon Village Inc. to store this information in compliance with payment processing regulations and to charge the card above for future payments in accordance with their terms. I understand that to make any changes to this authorization I must contact Horizon Village Inc. prior to the payment date.

Please include your Horizon Village 5-digit patient account number when submitting your payment.

If you have any questions please contact our office at 716-831-2700. Thank you for using our online convenient payment center.

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