Customer Payment Portal

Long Term Care - ACH Payment Portal

Hello! Thank you for your business! Use this secure form to make online payments for yourself or a loved one. Thank you!
Who are you making a payment for?*

MyselfSomeone other than myself
Name*

First NameLast Name
Resident Name (the individual you are making a payment for)*

First NameLast Name
Community Name: *
Community Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Name*

First NameLast Name
Your Phone Number*
Your E-mail*
example@example.com
In accordance with section 5-2-212 of the Colorado Revised Statutes, a processing surcharge may be applied to transactions made with a credit charge card or payment gateway (includes ACH) to offset the processing costs incurred by the seller or lessor. This surcharge will not exceed the merchant discount fee related to the sales or lease transaction. No surcharge will be applied to payments made via debit card, HSA or FSA cards, or gift card redemption.
Amount*
ACH Surcharge
Total with Surcharge
Payment Amount*

prevnext( X )
USDDescription

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The payment is ready! It will be completed once you submit the form.
If you have any questions, please contact our team at 970-461-9101 option 4. Thank you for using our online convenient payment portal.
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Long Term Care - ACH Payment Portal