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
Processing Fee Rates:
Cards:
2.5% ($2.50 min)
(4% for foreign cards)
eCheck (ACH):
$0.75
Name on Account:
Routing Number:
Account Number:
Institution:
Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:
Change Payment Method
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