Credit/Debit Card Payment – Child & Adolescent Behavioral Health

Child and Adolescent Behavioral Health Billing Department

330-454-7917

MasterCard

American Express

Discover

Billing information

Billing Information

Child and Adolescent Account Information

Amount *

Account Number *

Personal Information

First Name

Last Name

Address

Address

Address

Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Email

Phone

Payment Information

Credit Card

Credit Card

Credit Card

Credit Card

Credit Card

Credit Card

Your customer ID should be your Account Number from the top right corner of your statement. Thank you for your payment!

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