Received a Bill?

By completing this form, you will expedite the processing of your ambulance bill. All information is securely transmitted, and our firm abides by all Federal HIPAA Privacy Regulations

This questionnaire does not require that all field be complete. Please complete the sections that you believe pertain to your situation.

Printed at the top of your bill, what ambulance company transported the patient?
Printed in the upper right hand corner of your bill, please type in the Call/Patient ID #
Date of Service
Patient's First Name
Patient's Middle Initial
Patient's Last Name
Patient's Street Address
City
State/Territory
Country
Zip or Postal Code
Patient's Date of Birth
Home Telephone
Mobile or other Telephone
Email Address
Relationship to the insured


IF YOUR CALL WAS RELATED TO A MEDICAL SITUATION, PLEASE COMPLETE ALL APPLICABLE AREAS

MEDICARE PATIENTS

Medicare Identification Number including any letters and numbers
Medicare Advantage Plan Number including any letters and numbers
Medicare Advantage Plan Name
Medicare Advantage Plan Address
City
State/Territory
Zip or Postal Code
Customer Service Telephone (from identification card)


MEDICAL ASSISTANCE/MEDICAID PATIENTS

Medical Assistances/Medicaid Identification Number including any letters and numbers
Medical Assistance/Medicaid Managed Care Plan Number including any letters and numbers
Medical Assistance/Medicaid Managed Care Plan Name
Medical Assistance/Medicaid Managed Care Plan Address
City
State/Territory
Zip or Postal Code
Customer Service Telephone (from identification card)


COMMERCIAL HEALTH INSURANCE PATIENTS

Insurance Company Name
Member or Subscriber Number including any letters and numbers
Group Number
Subscriber Name (If different from patient name)
Subscriber Address (if different from patient)
City
State/Territory
Zip or Postal Code
Subscriber Date of Birth (If different from patient)
Subscriber Telephone Number (If different from patient)
Subscriber email address (if different from patient)
Address for Claims Submission
City
State/Territory
Zip or Postal Code
Customer Service Telephone (from identification card)


Secondary Insurance Company Name
Member or Subscriber Number including any letters and numbers
Group Number
Subscriber Name (If different from patient name)
Subscriber Address (if different from patient)
City
State/Territory
Zip or Postal Code
Subscriber Date of Birth (If different from patient)
Subscriber Telephone Number (If different from patient)
Subscriber email address (if different from patient)
Address for Claims Submission
City
State/Territory
Zip or Postal Code
Customer Service Telephone (from identification card)


AUTOMOBILE ACCIDENTS PATIENTS

Insurance Company Name
Policy Number
Claim Number
Medical Bill Submission Address
City
State/Territory
Medical Claim Adjuster Name
Medical Claim Adjuster Telephone Number
Medical Claim Adjuster Email Address
Health Insurance Company Name (For use with benefit exhaustion)
Member or Subscriber Number including any letters and numbers
Group Number
Subscriber Name (If different from patient name)
Subscriber Address (if different from patient)
City
State/Territory
Zip or Postal Code
Subscriber Date of Birth (If different from patient)
Subscriber Telephone Number (If different from patient)
Subscriber email address (if different from patient)
Address for Claims Submission
City
State/Territory
Zip or Postal Code
Customer Service Telephone (from identification card)


WORKMANS COMPENSATION PATIENTS

Name of Employer
Insurance Company Name
Policy Number
Claim Number
Medical Bill Submission Address
City
State/Territory
Zip or Postal Code
Claim Adjuster Name
Claim Adjuster Name
Claim Adjuster Email Address