2021 Secure Payment Request Form
indicates required fields
the invoice number(s)and amount(s).
If you don't have invoice number(s), just enter amount(s).
If you are updating the credit card for automatic payments on your account, you can skip this section.
Total Amount to PayRecalculate
I authorize HIS to use
this credit card for:
This payment only
If any of the required fields are incomplete,
you'll be prompted to go back and fill-in the missing information.
When the information is submitted correctly, you should see a confirmation page and receive an email confirmation within 24 hours after you submitted this form.
If you don't see the confirmation page and do not receive the email,
your payment request did not go through.