Cetronia - Health on Wheels
Caas
Payment
 
Submit Online Payment for Cetronia Ambulance Invoice by completing the following form:
* Required Field
PATIENT INFORMATION
Patient Name*
Street Address*
Street Address 2
City*
State*
Zip Code*
Phone Number*
Email Address*
 
BILLING INFORMATION
(must match the address on file with your financial institution)
Billing Information is same as Patient Information.
Cardholder's Name*
Street Address*
Street Address 2
City*
State*
Zip Code*
Phone Number*
 
PAYMENT INFORMATION
Run / Call Number* Run / Call Number
Billing Date*
Total Charge from Invoice*
Online Early Payment Discount
Discount will be validated and an additional 5% will be due if payment is not eligible for the applied discount.
Payment Amount
Payment Method*
Credit Card Number*
Expiration Date (MM/YYYY)*
Security Code* (What Is This?)
 
All invoices paid online within 10 days of the invoice date will receive a 5% discount.
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