One Time ACH Payment Payment Details*This information is requiredResident Name* First Last Medical Record #* Payment Amount* Choose Location*Choose OneHickory Point Christian Village. 565 W Marion Ave., Forsyth, IL 62535Johnson Christian Village. 7102 State Road 158, Bedford, IN 47421Lewis Memorial Christian Village. 3400 W Washington, Springfield, IL 62711Risen Son Christian Village. 3000 Risen Son Blvd, Council Bluffs, IA 51503River Birch Living. 4012 Cockrell Ln, Springfield, IL 62711Spring River Christian Village. 201 S Northpark Ln, Joplin, MO 64801The Christian Village. 1507 7th St, Lincoln, IL 62656Timberlake Supportive Living. 2521 E Empowerment Rd, Springfield, IL 62703Wabash Christian Village 216 College Blvd, Carmi, IL 62821Wabash Estates, LP. 532 Abelson Drive, Carmi, IL 62821Washington Village Estates, LP. 1150 Newcastle Road, Washington, IL 61571Carelink – 1999 Wabash Ave, Ste 202, Springfield, IL 62704Carelink Metro – 122 Lincoln Place Ct, Ste 202, Belleville, IL 62221Billing Details*This information is requiredEmail (for receipt of payment)* Phone*Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Bank Transfer Account holder Name * Account Number * Routing Number * Account Type * Choose One.. Checking Savings Check Type * Choose One.. Personal Business PAYMENT TERMS AND CONDITIONS*AUTHORIZATION By checking the "I accept the Terms and Conditions" checkbox below I authorize my bank to debit my specified account for the amount of my payment. This is a one-time payment which will occur on the next business day or as soon as practical thereafter. If my payment cannot be completed for any reason, including insufficient funds or error in the information which I submitted, I will retain the same liability, which is my sole responsibility, for payment as though I had not attempted to make the payment. I also understand that additional fees and penalties may be collected to the extent of applicable law. RECEIPT A receipt can be printed after payment is accepted which may serve as evidence of payment. If an email address is provided during the payment process, a receipt will be emailed to you after the payment is processed. CONTACT If for any reason you wish to make a change to the payment after submission, please contact Christian Horizons Living for assistance at (314) 587-7900 I agree to the terms and conditions. Total $0.00 CAPTCHA
