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CITY OF MCKINNEY AMBULANCE PAYMENT FORM

* Information requested below with an asterisk is located on your patient invoice.

PAYMENT SUMMARY:
Date: 12/11/18
Payment Amount:
Account Number: *
Incident #:
Invoice Date: *
Service Date: *
CREDIT CARD INFORMATION:
Card Type:

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.