Valley Behavioral Health
It looks like you have turned off JavaScript functionality. You will be automatically forwarded to a version of this application that does not require javascript. If this redirect does not happen you can click on the following link to go to this version
Redirect
Transaction Total
Dollar Amount: $
Customer Information
Patient Name:
Patient Date Of Birth:
Billing Address
Billing First Name:
Billing Last Name:
Address:
City:
State:
Zip:
Country:
Phone:
E-Mail:
Card Information
Card Number
Exp. Date
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
Card Security Code:
What is this?
X
Card Security Code
For your protection, we require that you enter the Card Security Code (CSC) from your credit card.
Visa/Mastercard/Discover
The
three-digit
CSC code is printed on the signature panel on the
back
of the card immediately after the card's account number.
American Express
The
four-digit
CSC code is printed on the
front
of the card above the card number. Note that this is not an embossed code; it is printed directly on the plastic.