Group Admin Online Bill Pay

Account Information
Business/Group Name*
AllyHealth Group ID #*
Group Administrator Name*
First Last
Payment Information
AllyHealth Invoice Number*
Enter Payment Amount*

Please note that we now add a 3% surcharge for all credit card payments.
3% Credit Card Surcharge:
Price: $0.00
Total
$0.00
Please sign my group up for automatic billing each month using selected payment method..
- Yes, I'd like to pay each month's bill conveniently as an auto-pay customer.
Payment Method:*
- ACH (eCheck)
- Credit Card
Bank Information
ACH (eCheck) Information:*
Name on Account Bank Name Routing Number Account NumberAccount Type
For the "Name on Account" field, please fill in your first and last name.
Cardholder Information
Credit Card Payment Information*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date - Month/Year Security Code Cardholder Name
Billing Information:
Billing Address*
Street Address City State / Province / Region ZIP / Postal Code
Contact Phone*
Email to Send Payment Confirmation*
Name
This field is for validation purposes and should be left unchanged.

Account Information