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Test EMS Payment Gateway

Test EMS Payment Gateway

Hamilton Health Care System
706.272.6000
hamiltonhealth@hhcs.org

Content content content

EMS Authorize.net

Name as it appears on card * Required
First Last
Billing Address * Required
Street Address Address Line 2 City State ZIP Code
Email * Required
Phone * Required
Patient ID * Required
Patient Name: * Required
First Last
Ticket #
Desired Payment Amount * Required
Credit Card * Required

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name