Carbon County Amubulance
             
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
HealthSV 800-764-0844 Clinton UT

Payment Information
Method of Payment:
Processing Fees: Credit cards: 2.5% ($1.50 min)
                    (+1.5% processing fee for foreign cards)
eChecks: $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:
Credit Card Number:
Expiration Date: /
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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