City of Mckinney Online Payment Form

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:

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: