Med-Alert International Corp 

Invoice Payment Form

If paying by check: By submitting this form you authorize Med-Alert International Corporation to draft a check on your bank account for the amount shown below. If paying by check, you will receive a copy of the check in your next monthly bank statement. If paying by credit card you agree to abide by your cardholder agreement and by pushing submit you agree to the charges you submit.                

* = Required Information

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** Important Notice **

*If paying by check; by entering the amount and pressing SUBMIT you agree to allow Med-Alert International Corporation (MIC) to draft a check for the above amount if paying by check. All returned checks will be subject to a collection fee not to exceed $35 and will vary from state to state. 

*If paying by credit card you acknowledge that declined or disputed credit cards are subject to a $49 processing fee. You also agree to the terms and conditions of your credit card agreement. By submitting this payment you agree to use the payment method above to pay for this invoice(s).

 

Please provide the following information for PAYMENT:
Authorizing Name on Check or Card *
Company Name 
Address * 
City *  State *  Zip *
Phone Number * 
email Address 

Invoice(s) Paid *

Pay by MasterCard / VISA     NOTE: Med-Alert now also accepts the AMERICAN EXPRESS Card
Card Number  Exp. Date (MM/YYYY)
*NOTE: Credit Card billing will appear as "Med-Alert International Corp."

Be sure to press Submit below to process payment. You will see a conformation screen if the data has been properly sent. Thank you.

Pay By Check
Bank Name *
Bank City  Bank State 
Fraction (Example 5-215/1011) At Top Right of Check or under BANK NAME *
Check Number * 
Account Number *
Routing Number *


Enter Total sequence at bottom of your check / left to right: (Put a "/" for any symbols as indicated below, your order may vary)  *

 

 

 Enter The TOTAL amount of your Payment: $

      

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