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: