Payment Category



Account Number



Patient or Customer Name



Account Balance ($) Payment (Min: $5 Recommended: $25)






Reoccurring Payment Number of Months to Pay in Full






Payment Date Fees if Applicable




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Payment Categories:

  • STAT TRANS Service
    Wheel Chair or CAB Transport Service provided to a Patient or Customer

  • STAT Ambulance Service
    Emergency or Non-Emergency Medical Ambulance Transportation Services

  • SETEC Education & Training
    Education and Training Services provided to an employee, customer or student

Fees:

  • ($1.50 fee will be charged monthly for payments less than $25.00)

  • Fee for Time Payment of Greater than 12 Months (13+ Months): 5% of total

Discounts:

  • 2% DISCOUNT for One (1x) Payment in Full for Balances of $150.00 or less

  • 5% DISCOUNT for One (1x) Payment in Full for Balances of $500.00 for greater

  • Discounts will be reflected in your payment amount on the next page.
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