Annual Comprehensive Family Plan 2026 Payment Page

ANNUAL COMPREHENSIVE FAMILY PLAN 2026 PAYMENT PAGE
Your Name

First NameLast Name
Please include the name of one child in your family who will be covered under the Annnual Comprehensive Family Plan

First NameLast Name
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
office@premierpedsbh.com
example@example.com
Account Number (if known)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time

Hour Minutes

AM/PM Option
Number of children in your family
One Child
Two Children
Three or more Children
PAYMENT MAY BE ENTERED ON THIS FORM BELOW, OR LEAVE THE PAYMENT FIELDS BLANK AND YOU WILL BE REDIRECTED TO A PAGE ON OUR WEBSITE DISPLAYING OTHER PAYMENT OPTIONS

USD

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

When you click Submit below only your demographic information is sent to our office. Credit card information is sent securely directly to the credit card processor. If payment has not been made on this form please use one of the options displayed on the page on our web site you will be directed to next.

No credit card information is sent to or stored by our office
Should be Empty: