Secure Payment Form

 

This payment portal is intended for patients to make payments on the their call account for outstanding balances. All payments and charges made through this portal are considered final for services the patient received from the ambulance provider

Patient and Call Information:
Call Number on Bill:
Date of Call/Service:
Ambulance Service Used:
Patient First Name:
Last Name:
Patient Address:
Address Line 2:
City:
State:
Zip:
Country:
Phone Number:
Email Address:
          
Credit Card Information:
Date:05/20/18
Customer IP: 54.81.68.240 
Payment Amount:
Call Number on Bill:
Card Type:

Name as on Card:
Card Number:
Card Expiration Date: MMYY
Card ID (CVV2/CID) Number:
 
[What is the Card ID?]
   
You must fill out the credit card bill to information below even if it is the same as above.
Company Name (if applicable):
Card Holder First Name:
Last Name:
Card Holder Billing Address:
Address Line 2:
City:
State:
Zip:
Country:
     
Patient Insurance Information:
Name of Primary Insurance Company:
Name of Insured:
Policy Number:
Name of Secondary Insurance Company:
Name of Insured:
Policy Number: