Payment

Submit Online Payment for Cetronia Ambulance Invoice by completing the following form:
* Required Field
PATIENT INFORMATION
Patient Name*
Street Address*
Street Address 2
City*
State*
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*
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*
Credit Card Number*
Expiration Date (MM/YYYY)*
Security Code* (What Is This?)

All invoices paid online within 10 days of the initial first invoice date will receive a 5% discount.