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
Account Number* Account Number
Statement 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?)