Ambulance Service Fee

Help information for Name of Patient
In the space provided enter patient's first and last name. No nicknames please.

Help information for Date of Service
In the space provided enter date of service.

Help information for Patient ID Number
In the space provided enter your 6 to 8 digit patient ID number. Please include the dash when entering the number.

In the space provided enter amount you are submitting for payment.

Subtotal Amount
Service Fee
Payment Amount