Online Ambulance Bill Pay

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.