Ambulance Service Fee

Help information for Customer ID #
In the space provided enter the 8 digit customer ID number without dashes or spaces. Click the ? to see an example.

Help information for Date of Service
Enter the date of service in the space provided. Click the ? to see an example.

Help information for Name of Patient
Enter the first & last name of the patient in the space provided to continue. Click the ? to see an example.

Help information for Amount
In the space provided enter the amount you are submitting for your ambulance bill. Click the ? to see an example.

Subtotal Amount
Service Fee
Payment Amount