Make an IMAT Payment

Complete the form below to submit an on-line payment for medication-assisted treatment.

ID#

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First Name

Last Name

Phone

Payment Amount

Select a Payment Method

Cardholder Name

Credit Card #

Expiration Date

Security Code

Billing Zip Code

Account Holder

First Name

Last Name

Account Type

Account Number

Routing Number

Make this a monthly payment?

Make this a monthly payment?

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

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