Goldwater Care Payment Portal

Choose the Facility(Required)

Resident Name(Required)

First Name Last Name

Payment Type(Required)

One-Time Payment

Monthly Recurring Payment

Number of Months(Required)

Please enter a number from 2 to 36.

Please select a number of months for recurring payments between two (2) months and 36 months.

Room and Board Payment:

Payment amount above to be applied to customer room and board only.

Resident Spending Account:

Payment amount above will be allocated to the resident’s spending account.

Total:

Payment Method(Required)

Credit Card

Bank Account/ACH Transfer

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Bank Account Information(Required)

Account Number Account Type Routing Number Account Holder Name

Billing Address(Required)

Billing Address City State ZIP Code

Email Address(Required)

Telephone Number(Required)

Notes/Memo

Today's Payment Amount

Charges will appear as Goldwater Care on your statement.

Electronic Signature(Required)

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