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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>