Secure Payment Request Form

 

* indicates required fields

Date: 04/30/24
  Account Information  
*Name
(First,Mi, Last)		  
* Email   * Phone  
Organization  
HIS Account Number  
  Invoice Information  
 

Enter the invoice number(s)and amount(s).
If you don't have invoice number(s), just enter amount(s).
If you are updating the credit card for automatic payments on your account, you can skip this section.

 
Invoice Number Amount
$ 
$ 
$ 

Total Amount to Pay
Recalculate

 $ 
 
  Credit Card Information  
*Credit Card Type




 

* Frequency

I authorize HIS to use this credit card for:

 
*Name as it appears on the Credit Card (First,Mi,Last)
*Credit Card Billing Address
*Credit Card Number *Expiration
* CVV2
Comments/
Special Requests		  
 

If any of the required fields are incomplete, you'll be prompted to go back and fill-in the missing information.
When the information is submitted correctly, you should see a confirmation page and receive an email confirmation within 24 hours after you submitted this form.

If you don't see the confirmation page and do not receive the email,
your payment request did not go through.