Privacy Practices Patient Information Industry Links 270.824.8123
 ABOUT 911 BILLING
 OUR SERVICES
 INDUSTRY NEWS
 CUSTOMER TESTIMONIALS
 INFORMATION REQUEST
 CONTACT US
 911 EMPLOYEE PAGE
 911 SIREN NEWSLETTER
 KAPA
 Revenue Increase
 Research Material
 Make an Online Payment

 

911 Billing
Services & Consultant, Inc.
1320 Island Ford Road
Madisonville, Kentucky 42431
Phone: 270-824-8123
Toll Free: 1-888-344-9614

 

 
Forms For Patient Use

About | Our Services | Industry News | Testimonials | Info Request | Contact Us

<html>

<head>

<title>PaymentPage</title>

</head>

<body>

<form method="POST"

action="https://va.eftsecure.net/eftcart/forms/express.asp">

<input type="hidden" name="M_id" value="270488220195">

<table border="1" width="100%">

    <tr>

        <td>Amount:</td>

        <td><input type="text" name="T_amt" size="20" value="100.00"></td>

    </tr>

    <tr>

        <td>Tax:</td>

        <td><input type="text" name="T_tax" size="20" value="7.75"></td>

    </tr>

    <tr>

        <td>Shipping:</td>

        <td><input type="text" name="T_shipping" size="20" value="9.95"></td>

       </tr>

   </table>

<input type="submit" value="Submit">

</form>

</body>

</html>