DAGGETT COUNTY AMBULANCE
If you have any questions concerning your bill please call 435-784-3222, Ext. 410
Account No.
Ambulance Fee:
$
Item Subtotal:
$0.00
Patient's Name
[1]
Patient's Name
[2]
Patient's Name
[3]
Patient's Name
[4]
Patient's Name
[5]
Patient's Name
[6]
Patient's Name
[7]
Patient's Name
[8]
Patient's Name
[9]
Patient's Name
[10]
Total:
$0.00
Personal Information:
First Name:
Last Name:
Address:
Address:
City:
State/Province:
ZIP/Postal Code:
Phone:
Email:
Please be aware that your credit card statement will read
Health Services 800-764-0844.
Payment Information
Method of Payment:
Visa
MasterCard
Discover Card
Personal Checking
Personal Savings
Business Checking
Processing Fee Rates:
Cards:
2.5% ($2.50 min)
(4% for foreign cards)
eCheck (ACH):
$0.75
Update name from
Personal Information
Name of Individual
on Checking Account:
Name of Individual
on Savings Account:
Name of Business
on Checking Account:
Bank Routing Number:
Bank Account Number:
Confirm Account Number:
Credit Card Number:
Expiration Date:
01
02
03
04
05
06
07
08
09
10
11
12
/
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
Card ID (CVV2/CID) Number:
What is the Card ID?
Cardholder Information
(exactly as it appears on your statement)
Update from
Personal Information
Cardholder's Name:
Billing ZIP/Postal Code:
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