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FMS Pay — Virtual Card Request & Agreement
For ongoing services and registrations that need a card number — let's get you set up.
To enhance our participants' access to various services, FMS Pay is pleased to offer the issuance of a virtual credit card in appropriate circumstances. Virtual cards are primarily intended for ongoing service arrangements. Common scenarios: monthly gym memberships; monthly cell phone or internet plans; registration or one-time payments for activities such as YMCA memberships, swimming lessons, or karate classes; and situations requiring access to the client's private account, preventing the need to share login credentials (e.g., online tutoring registration). To mitigate misuse and limit fraud exposure, each virtual card is linked to a specific merchant — for instance, a card requested for a monthly AT&T cell phone bill will only authorize transactions with AT&T.
What is this virtual card for?
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An ongoing service or subscription (e.g., gym membership, cell phone plan, internet)
A registration or one-time payment for an activity (e.g., YMCA, swim lessons, class registration)
Access to the client's private account without sharing login credentials (e.g., online tutoring)
A physical item or product
⚠ Virtual cards cannot be issued for physical items — these are purchased directly by FMS Pay. Please use our
One-Time Purchase Request form
instead; this form cannot be submitted for physical items.
Client Information
Client Name
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UCI #
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Your Regional Center client number (also called UCI). Ask your case manager if you're not sure.
Regional Center
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Contact email
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We'll use this if we have questions about your request.
Contact phone
Please enter a valid phone number.
Format: (000) 000-0000.
Virtual Card Request Specifics
Merchant Name
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The card will ONLY work at this merchant.
Product/Service Requested
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Amount
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Per charge — e.g., $45.99
Frequency
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One-time payment
Monthly recurring
Other
If Other, please describe the frequency
Invoice / Contract / Backup Documentation
Upload a File
Drag and drop files here
Choose a file
Attach the invoice, contract, registration page, or other documentation supporting this request, if available. If the business provides the receipt after the transaction (e.g., a gym membership agreement), you can skip this — receipts must still be emailed to connect@fmspay.com after the transaction.
Cancel
of
Participant & Independent Facilitator Virtual Card Agreement
Spending plan & IPP alignment
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I acknowledge that the above request is supported by my existing spending plan on file with FMS Pay LLC and aligns with the goals established in my Individual Program Plan (IPP) with the Regional Center. Should this not be the case, the request will be declined.
In plain words: this request must match your spending-plan and your IPP goals, or it will be declined.
Receipts commitment
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I commit to submitting accurate and timely receipts for all transactions to connect@fmspay.com, clearly indicating the services or support received and their associated costs. I understand that failure to provide a receipt or any misuse of the virtual card will result in the immediate termination of the card and may restrict my ability to request virtual cards in the future, and that any misuse will be reported to the Regional Center's case management team and the Department of Developmental Services (DDS).
In plain words: send your receipts to connect@fmspay.com every time you use the card. No receipts, or wrong use of the card, means the card is turned off.
Cancellations & card termination
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If I am requesting an ongoing monthly amount, I agree to promptly inform FMS Pay should I wish to cancel the card or alter the authorized amount. FMS Pay will not be liable for any charges incurred if I fail to notify the company in a timely manner regarding cancellations — for example, if I enroll in a monthly gym membership and neglect to cancel. I understand FMS Pay reserves the right to terminate the virtual card if there are insufficient funds available in the service code or if the budget year concludes without a new spending plan submission.
In plain words: if you stop using a monthly service (like a gym), tell FMS Pay right away so we can stop the payments.
Charges, refunds & liability
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All charges on the card will be deducted from the participant's spending plan. The virtual card functions as a credit card, not a prepaid card. Any refunds processed will be allocated back to the spending plan; however, frequent returns may necessitate termination of the virtual card due to difficulties issuing refunds to the Regional Center. All charges are expected to be final and refunds should be considered rare; in certain cases the merchant may be unable to issue a refund, particularly after the virtual card has been terminated. FMS Pay does not endorse specific goods or services and offers no guarantees, warranties, or assurances of customer satisfaction; all purchases may be final subject to the merchant's return policies, and FMS Pay cannot be held accountable for buyer's remorse, dissatisfaction, or defective, damaged, or misadvertised products. FMS Pay is not responsible for circumstances beyond its control, such as the merchant's failure to deliver, delivery of incorrect products or services, or loss or theft during shipping, including porch piracy. I confirm I have provided FMS Pay with my accurate and valid shipping address.
In plain words: charges come out of your spending-plan. Most purchases are final — refunds are rare. FMS Pay is not responsible if a product or service disappoints or a delivery goes wrong.
Printed Name
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Signature
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Date Signed
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Month
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Day
Year
Date
Submit Request
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