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Payment
Submit Online Payment for Cetronia Ambulance Invoice by completing the following form:
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Required Field
PATIENT INFORMATION
Patient Name
*
Street Address
*
Street Address 2
City
*
State
*
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AZ
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CO
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DE
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ID
IL
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Zip Code
*
Phone Number
*
Email Address
*
BILLING INFORMATION
(must match the address on file with your financial institution)
Billing Information is same as Patient Information.
Cardholder's Name
*
Street Address
*
Street Address 2
City
*
State
*
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip Code
*
Phone Number
*
PAYMENT INFORMATION
Run / Call Number
*
Billing Date
*
Total Charge from Invoice
*
Online Early Payment Discount
Discount will be validated and an additional 5% will be due if payment is not eligible for the applied discount.
Payment Amount
Payment Method
*
Visa
MasterCard
Credit Card Number
*
Expiration Date (MM/YYYY)
*
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2021
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Security Code
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