Online Payment Service by VPS

1

Payment
Details
2

Review
Information
3

Payment
Receipt

Payment Type : Springfield Hospital

Please enter your information below and select "Continue" to proceed to Review Information.

Account Information

Check here if address is international.

First Name*

Last Name*

Account Address*

Account Address Continued

City*

State*
Select a State

Zip Code*

Province/Region*

Postal Code*

Country*
Select a Country

Contact Phone Number*

Email Address

Payment Information

Payment Amount*

$

.

Account Number*

Confirm Account Number*

Or Use A New Payment Method

Payment Method*
--

Card Number*

Expiration Month*
Month

Expiration Year*
Year

Billing Information

Billing Information is the same as above.

Check this if card address is international.

Cardholder First Name*

Last Name*

Billing Address Line 1*

Billing Address Line 2

City*

State*
Select a State

Zip Code*

Province/Region*

Postal Code*

Country*
Select a Country

Check Type*
Select Check Type

Bank Routing Number*

Account Number*

Confirm Account Number*

Business Name*

Sample Check

Billing Information

Billing Information is the same as above.

PaymentDetails

ReviewInformation

PaymentReceipt

Account Information

Payment Information

Billing Information

Billing Information

Payment
Details

Review
Information

Payment
Receipt