Ambulance Service Fee
Customer ID #
In the space provided enter the 8 digit customer ID number without dashes or spaces. Click the ? to see an example.
Date of Service
Enter the date of service in the space provided. Click the ? to see an example.
Name of Patient
Enter the first & last name of the patient in the space provided to continue. Click the ? to see an example.
In the space provided enter the amount you are submitting for your ambulance bill. Click the ? to see an example.
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