Insurance Information

To help us file a claim with your insurance carrier, please complete the form below and
press the 'Submit' button. Thank you.

* Required Fields

Patient Information

Invoice Number *

Date of Service *


MM	DD	YYYY

First Name *

Last Name *

Date of Birth


MM	DD	YYYY

Phone Number

Patient Representative

First Name

Last Name

Relationship to Patient


		if other, please provide

Phone Number

Insurance Information

Medicare Number
Medicaid Recipient ID

Primary Health Insurance

Primary Insurance Name

Insurance Address


Street


Apt., Suite, etc.


City	State	Zip

Insurance Phone Number

ID Number

Group/Plan Number

Name of Insured

Secondary Health Insurance

Secondary Insurance Name

Insurance Address


Street


Apt., Suite, etc.


City	State	Zip

Insurance Phone Number

ID Number

Group/Plan Number

Name of Insured

Check this box if the ambulance service provided was the result of an employee accident

Employer Name

Worker's Compensation
Insurance Name

Insurance Address


Street


Apt., Suite, etc.


City	State	Zip

Insurance Phone

Claim Number

Check this box if the ambulance service provided was the result of an
automobile accident

Automobile Insurance Name

Insurance Address


Street


Apt., Suite, etc.


City	State	Zip

Insurance Phone Number

Claim Number

Patient is a member of an ambulance company

Name of Ambulance Company

Comments / Special Instructions: