CFFP Payment Form

Payment Details*

USDMedical Services Payment and Co-Payments Amount

Payer Phone Number*
Payer E-mail*

Confirmation Emailexample@example.com
By clicking Submit below, I authorize, Center for Family Psychiatry, PLC, to charge the amount listed above to the credit card provided herein. I agree to pay for this purchase in accordance with the issuing bank cardholder agreement.
Payment submitted
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Type a question
Should be Empty: