EMSBillPay.com
Fields marked with an (*) are required.


Step 1: Bill Details

You have received a bill that should look similar to the one below. Please use the information from YOUR bill in the fields below.

Bill

Ambulance Name: *
Run Number: *
Date of Service: *






Step 2: Patient Information

First Name: * Last Name: *
Address: *
Address 2:
City: * State: *   Zip: *
Phone: *
Date of Birth: / / * (example: 08/14/1979)
SSN: - -
Email Address: *


Step 3: Payment Options



Comments:

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