Patient Notebook

Patriot Ambulance Service, Inc

5189 Commerce Road

Flint, MI 48507

Phone: (810) 742 - 5391

Fax: (810) 600 - 2418

Email: billing@patriotambulance.net

Website: www.patriotambulance.net

Make a Payment

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Error Summary

Please, correctly fill out all required fields.

1. Patient Information

First Name *

M.I.

Last Name *

Dates of Service *

Enter statement date if DOS is not available

Invoice #

Enter the Account No as listed on statement

Invoice Date

Enter the statement date listed on statement

Account NO *

Enter Account No (Run #) as listed on statement

Email Address

A receipt will be sent to this email address.

2. Payment Amount

Amount

3. Payment Method

Credit/Debit Card

Name on Card *

Card Number *

Expiration Date *

Security Code *

Zip Code *

Cancel

P (810) 742 - 5391

F (810) 600 - 2418

W www.patriotambulance.net

5189 Commerce Road

Flint, MI 48507