Pay by Check – Child & Adolescent Behavioral Health

E-check form

Amount *

Account Number (this is a 10 digit number - please place 5 or 6 zeros before entering account number) *

First Name

Last Name *

Address

City

State/Province

Zip/Postal

Phone Number

Name on Account

ABA Routing Number *

Bank Account Number (enter number without spaces or dashes) *

Bank Name

Banking Account Type

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