Billing / Payment Update

Practice Information

Business Name(Required)

Contact Name(Required)

First Last

Contact Email(Required)

Phone(Required)

Address(Required)

City State

Billing Information

Payment Options(Required)

eCheck

Credit Card

Please choose the payment option you would like us to keep on file for your account.

Credit Card Information

Name on Card(Required)

Card Type(Required)

Credit Card Number(Required)

(Visa, Mastercard, Discover)

Credit Card Number(Required)

Expiration Date(Required)

SEC Code(Required)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

eCheck Information

Name on Account(Required)

Account Number(Required)

Routing Number(Required)

Please Upload an Image of a Voided Check

Max. file size: 2 MB.

A picture of a voided check is necessary to verify your account information. If you do not have a voided check available to upload at this time, please email to ar@podmarketinginc.com.

Payment Update

Billing / Payment Update

Practice Information

Billing Information

Credit Card Information

eCheck Information

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