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ALLINA TRANSP WEB PYMT
ALLINA TRANSP WEB PYMT
167 GRAND AVENUE
ST PAUL,MN 55102
(651) 222-6040

STEP 1
Payment
       
STEP 2
Confirm
       
STEP 3
Receipt
Payment Type

           
Credit Card Bank Account

Patient
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Patient ID PatientMedicalRecordNumber First Name Last Name Birth Date PatientServiceBeginDate PatientServiceEndDate AdditionalInfo1 Additional Info 2 Additional Info 3 Additional Info 4 Additional Info 5 Additional Info 6 Amount
Add Row Total $0.00
Allina Transportation Invoice Number
Last Name
First Name  Middle :
  (MM/DD/YYYY)
 -  - 
Email Address
       Zip    -
Zip    -
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Payment Information

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Card :
Card Holder Name
Card Type
Card Number   Exp Date   (MM/YY)
CVN   What is this?
Amount            Current Balance  
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Account Information

       Zip    -
Zip    -
 -  - 
  Your credit card/bank account will not be charged
until all information is confirmed in the next step.
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