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Alachua County Board of County Commissioners
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Online Ambulance Bill Pay

Credit card payment authorization form

Please fill out all the fields in this form before submitting your information for payment.

Account Information
Fire Rescue Call or Patient Number
Name On the Account

Enter the Name on the Credit Card

First Name:
Last Name:
Email Address
Address Information

Enter the address where you receive billing statements for this card. In order to verify your bank card number, the billing address must be the one displayed on your bank receipt.

Address
City
State
Zip Code
Telephone Contact Number
Credit Card Information
Card Type
Credit Card Number
Card Verification Number
(Last 3 digits on back of card - example)
Expiration Date
/
How much would you like to deduct from your card (min. amount $10.00)
$

Before Submitting Please insure that All the Information is Correct.
It could result in a delay in processing your payment.


This website is a public service. Please read the Legal Disclaimer. Website designed and engineered by Alachua County ITS.Applications Division Version 2010 (v1.0)

Under Florida law (Statute 119.011), all information, including e-mail, written letters, documents and phone messages, sent to the Alachua County Board of County Commissioners is subject to Public Records law. This includes the sender's e-mail address, home address or phone number if shown in the message, the content of the message and any associated attachments to the mail. Also please be aware that electronic correspondence (e-mail) is made available on the Commission's public archive site immediately upon being sent. Instead, contact Alachua County Offices by phone or in writing.