Make an IMAT Payment

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

ID# (Required)

First Name (Required)

Last Name (Required)

Phone (Required)

4cidte0m659v

Payment Amount (Required)

Select a Payment Method

Cardholder Name (Required)

Credit Card # (Required)

Visa MasterCard American Express Discover

Expiration Date (Required)

Security Code (Required)

Visa®, MasterCard® & Discover® cardholders
Your security code is the 3-digit code at the end of the signature field on your card's back.

American Express® cardholders
Your security code is the 4-digit code located above the actual credit card number on your card's front.

Billing Zip Code (Required)

Account Holder

First Name

Last Name

Account Type

Account Number (Required)

Routing Number (Required)

Make this a monthly payment?

Make this a monthly payment?

Your payment will be

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