CITY OF MCKINNEY AMBULANCE PAYMENT FORM
* Information requested below with an asterisk is located on your patient invoice.
PAYMENT SUMMARY:
Date:
10/30/24
Payment Amount:
<
Account Number:
*
Incident #:
Invoice Date:
*
Service Date:
*
<
CREDIT CARD INFORMATION:
Card Type:
Visa
MasterCard
Name as on Card:
Card Billing Address:
Card Billing Zipcode:
 *
Card Number:
Card Expiration Date:
MMYY
Card ID (CVV2/CID) Number:
[
What is the Card ID?
]
PATIENT INFORMATION:
Patient First Name:
Patient Last Name:
Physical Street Address:
City:
State:
Phone Number:
Email Address:
Comments:
City of McKinney | 222 N. Tennessee St. McKinney, Texas 75069 | Phone: 972-547-7500
©2009 City of McKinney. All Rights Reserved.