Piedmont Triad Ambulance & Rescue / Payment Page

We Use Hush Encryption Technology For Secure Online Payments!

Click the button above for detailed information about how our Secure Email Form below provides STRONGER encryption than SSL (Secure Socket Layer) technology used on most websites, and how our Secure Email Form - unlike SSL - automatically encrypts your information BEFORE it is stored.

We Accept The Following Credit Cards For Online Payments:

Enter Your PTAR Account Number In The Form Below
So We Can Apply Your Payment To The Correct Account.

All Fields Marked With An Asterisk

Must Be Filled Out.


PTAR Account #
Payment Amount$
SECTION-1: Enter Patient Information Below: All Fields Marked With An Asterisk Must Be Filled Out.
Patient Name
Patient Address1
Address2 (Optional)
City
State
Zip Code
Day Phone Number
Night Phone Number
SECTION-2: Person Making This Payment If You Are Same Person As Above ( If You Were The Patient ) You May Skip Section-2 And Continue To Section-3. If Different Than Above ( If You Were NOT The Patient ) Fill Out The Section Below If Making A Payment For The Patient. All Fields Marked With An Asterisk Must Be Filled Out.
Your Name
Your Address1
Address2 (Optional)
City
State
Zip Code
Day Phone Number
Night Phone Number
SECTION-3: Enter Credit Card Info Below: This Information Must Match Exactly What Is On Your Credit Card, And Your Credit Card Billing Statements, Or Your Payment CANNOT Be Processed. All Fields Marked With An Asterisk Must Be Filled Out.
Type of Credit Card
Name On Credit Card
Credit Card Number
Expiration Date	Example: 06 2015
Security Code Number
Enter Your Credit Card Billing Address
City
State
Zip Code
Your Email Address
TYPE YOUR COMMENTS, OR ADDITIONAL INSTRUCTIONS BELOW
	Thank You! A Receipt Will Be Mailed To The Billing Address You Entered Above.