Patient Notebook

Galesburg Hospitals' Ambulance

First Name *

M.I.

Last Name *

Trip Ticket *

Located below patient address information and starts with GHAS-

Contact Phone # *

Email Address

A receipt will be sent to this email address.

Payment Information

Make A Payment

Amount is required.

Installment Amount must be equal to or greater than the Minimum Installment Amount shown.

Installment Amount exceeds the Plan Balance.

You cannot set up a payment plan without submitting a valid email address.

First Payment Date is required.

Payment plans must start today or later.

Payment plans must start within one year.

First Payment Date is invalid.

How would you like to pay?

One-time Payment

Amount *

Choose a Payment Method

+ Credit/Debit Card

Credit/Debit Card

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Name on Card *

Card Number *

Expiration Date *

Security Code *

Zip Code *

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