Pay Online

Please note that due to increased costs there will be a $5.00 processing fee per transaction.

If you are using this to make a donation to your choice of agency, Please write down "Donation to XXX Ambulance" so we can apply the funds to the correct agency and no processing fee's will be assessed.

Patient Information

First Name*

Last Name*

Phone Number*

Email Address

Billing Information

First Name*

Last Name*

Billing Address

Order Information

Account # or Claim #*

Amount to Pay*

Credit Card Number*

Expiration Date

CVV Code

By checking this box,

You agree to pay the listed amount plus a maximum amount of $5.00 for processing fees. Logical Billing Solutions, Inc does not retain your credit card information for future payments and that each payment can incur processing fees.

I agree with the terms & conditions above