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Carbon County Ambulance Services
Account Information
Patient's Name
Payment Amount:
$
Item Subtotal:
$0.00
Total:
$0.00
Personal Information:
First Name:
Last Name:
Address:
Address:
City:
State/Province:
ZIP/Postal Code:
Phone:
Email:
Please be aware that card payments will be described as
CBT*Carbon County UT
Payment Information:
Processing Fee Rates:
Cards:
2.5% ($1.50 min)
(1.5% surcharge for foreign cards)
eCheck:
$0.75
Method of Payment:
Update Name from Personal/Organizational Information
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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SIP Version 3.09.15288; (API: 2.20)
