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 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 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.