Online Payment Portal

SouthBridge EMS Online Payment Portal
Patient's Name *

First Name Last Name
Phone Number *

- Area Code Phone Number
E-mail
example@example.com
Claim Number *
i.e. 17-123456
Date of Service

- Month - Day Year

Payment Amount

USD

Payment Method

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty: