Secure Payment Form
This is a HIPAA and Red Flag Secure and Compliant contact.

You will need information from your invoice to complete your payment. Please use the secure form below to submit payment to Schuylkill EMS. We accept VISA, Mastercard, Discover Card, and American Express.

If you enter your email address, you will receive email confirmation that your payment has been received.

*Required fields

Purpose of Payment

*Name of Ambulance Service:

*Run Number from Invoice:

*Payment Amount: (without the $ symbol)

Comments or Additional Information:

Patient Information

*Patient First Name:

*Patient Last Name:

*Patient Address:

*Patient City:

*Patient State:

*Patient Zip:

*Patient Phone:

*Patient Email:

Payment Details

*Credit Card #:

*Exp. Date:

*Card Holder Name: (as it appears on the card)

*CVV2 Security Code: ?

*Billing Address:

*Billing City:

*Billing State:

*Billing Zip:

All Sales Final. Submitting this form acts as a digital signature and your authorization for this transaction.