Carbon County Ambulance
             
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:
  Credit/Debit Card
  eCheck
 Update Name from Above
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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