Monthly Credit Card Installments Monthly Payment Details*This information is requiredPatient Name* First Last Account Number NOTE: Please calculate what your monthly payment amount should be and enter the first Installment amount below. The first installment payment will be made today once you submit this form. Your remaining payments will auto charge on the same day each month for the number of months you select in the dropdown menu. For example, if today is the 1st of the month, your first payment will go through today, and all following monthly payments will be charged on the 1st of each month. Your remaining payments will auto charge on the same day each month until the balance is paid off. To cancel the recurring payment, you will be required to call our business office at 913-491-4466 or email [email protected].How Many Times Your Payment Should Recur?*Please Choose One2 Installments3 Installments4 Installments5 Installments6 Installments7 Installments8 Installments9 Installments10 Installments11 Installments12 InstallmentsMonthly Payment Amount* CommentsBilling Details*This information is requiredContact Name* First Last Email* 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 A 10 business day advance notice is required to process the cancellation request. By submitting this form, you acknowledge that the first installment payment will be made today and agree to monthly installment payments.* I understand & acknowledge thisSecure Credit Card Card Holder* Card Number* Card Expiration* Card CVV* Total $0.00 CAPTCHA