Cornerstone Primary Healthcare

Please complete ALL sections. Once payment is processed, you will receive a TEXT confirmation and authorization number.

Account No.

Enter Acct # From Statement

Name on Account *

Amount to be charged *

Choose Payment Method *

Visa

MasterCard

Discover

American Express

HSA Acct.

these are the only acceptable forms for online payment

Credit Card Number *

Expiration Date *

mm/yy

Security Code *

3 or 4 digit number on card

Name on Card *

Contact Number for Confirmation *

*Phone must be able to receive texts

Please Note: Submit a separate form for each payment method being used.

* Required field