Patient Name :Patient Phone Number :Patient Acct # :Patient Address : Street Address City State / Province / Region ZIP / Postal Code Cardholder Name:Cardholder Address : Street Address City State / Province / Region ZIP / Postal Code Credit Card : MasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name This payment is for : Invoice # Payment Plan Self-Pay Items Amount To Be Paid:$Captcha Code :I authorize CMSI (Central Medical Systems, Inc.) to charge my credit card for the above amount. This is a one-time charge authorization. This information is submitted securely via SSL Security Certificate and the credit card information is not stored. Any questions regarding this transaction can be directed to CMSI’s Finance Manager at 407-365-7580. This iframe contains the logic required to handle Ajax powered Gravity Forms.