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UCP is honored that you have chosen us to provide therapy for your child.
Need Assistance?
UCP accepts all payment types, MasterCard, Visa, American Express and Discover, including Flexible Spending Accounts and/ or Health Savings Accounts. Co-pays, co-insurance and deductibles must be paid at time of service. If you have any questions or need assistance with making your payment, please call 480-372-2999 Monday- Friday from 8:00 am – 5:00 pm.
Child Information
Full Name
*
First Name
Last Name
Date of Birth
*
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Month
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Day
Year
Date
Parent Information
Full Name
*
First Name
Last Name
Phone Number
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Payment Information
Invoice Number
Payment Type
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Co-pay
Co-insurance
Other
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Payment Total
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USD
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Email
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