Make a Payment

<form action="https://hosted.transactionexpress.com/Transaction/Transaction/Index" method ="POST"> <!-- [et_pb_line_break_holder] --><input type="hidden" name="HostedKey" id="HostedKey" value="cff099df-fc36-4f64-9cf3-8b5ee3d08e6d" /> <!-- [et_pb_line_break_holder] --><input type="hidden" name="Gateway_ID" id="Gateway" value="9128195473" /> <!-- [et_pb_line_break_holder] --><input type="hidden" name="IndustryCode" id="IndustryCode" value="2" /> <!-- [et_pb_line_break_holder] --><input type="hidden" name="Amount" id="Amount" value="" /> <!-- [et_pb_line_break_holder] --><input type="hidden" name="RecurringType" id="RecurringType" value="N" /> <!-- [et_pb_line_break_holder] --><input type="hidden" name="RecurringAmount" id="RecurringAmount" value="" /> <!-- [et_pb_line_break_holder] --><input type="hidden" name="RURL" id="RURL" value="https://comportho.com/thankyou/" /> <!-- [et_pb_line_break_holder] --><input type="hidden" name="CURL" id="CURL" value="https://comportho.com/" /> <!-- [et_pb_line_break_holder] --><input type="hidden" name="AVSRequired" id="AVSRequired" value="Y"/> <!-- [et_pb_line_break_holder] --><input type="hidden" name="CVV2Required" id="CVV2Required"value="Y"/> <!-- [et_pb_line_break_holder] --><input type="hidden" name="EmailRequired" id="EmailRequired" value="Y"/> <!-- [et_pb_line_break_holder] --><input type="hidden" name="PostRspMsg" id="PostRspMsg" value="N"/> <!-- [et_pb_line_break_holder] -->Account Number: <input name="CustRefID" required="" type="text" value="" required/> <!-- [et_pb_line_break_holder] --><input type="hidden" name="SECCode" id="SECCode" value="2" /> <!-- [et_pb_line_break_holder] --><input type="hidden" name="Descriptor" id="Descriptor" value="Medical" /> <!-- [et_pb_line_break_holder] --><input type="Submit" name="Submit" id="Submit" value="Pay Now" /> </form>