EB2Gov POS

PLEASE ENTER YOUR INVOICE NUMBER IF AVAILABLE

PLEASE NOTE:

There are additional vendor processing convenience fees when making a payment online.

These fees are non-refundable.

HSA/FSA cards are not accepted for payment at this time.

PLEASE ENTER YOUR INVOICE NUMBER IF AVAILABLE

PLEASE NOTE:

There are additional vendor processing convenience fees when making a payment online.

These fees are non-refundable.

HSA/FSA cards are not accepted for payment at this time.

Ambulance Billing

Patient's Full Name:

Patient's Date of Birth:

Date of Service:

Invoice Number:

Full Name (if different from patients):

Phone Number:

Amount:

EB2Gov Fee:

Quantity:

Payment Amount:

Notes:

Upload Files:

image size limit is 4 MB, 5 images max