Billing Inquiry Form

Billing Inquiry Form
Your name?*

First NameLast Name
Call back number/number you want called back on?*
Please enter a valid phone number.
Do you have an email address? Often responses are usually quicker by email.
example@example.com
YesNo
Patient Name

First NameLast Name
Patient's date of birth if known?

MonthDayYear
Date
Date of Service?

MonthDayYear
Date
Do you have an invoice number or patient number?
Pay a billHave a question on a bill/insurance coverageProviding insurance informationSubscription questionOther
Credit Card
Credit cardCheckOther
Have you tried paying on our websiteTried but failed to go throughOther
You can go to our website at www.SouthBridgeEMS.com and across the top click patient Resources. The you can click "securely pay your SouthBridge bill".
What is your question on paying by check?
- Check are made out to SouthBridge EMS
- Mailing address is PO Box 142, Bridgeville, PA 15017
- Write the invoice number in the memo line of the check. If you don't have the invoice number, please write the patient number, or patient name and DOB in the memo line of the check
- Check usually take 2-3 weeks to process
Notes for calling about payment
Billing or insurance coverage question
What is your question
Providing insurance information
Insurance company name?
Group number
Insurance ID #
Please upload files here if available

Cancelof
Insurance information additional information
Other billing question
Reason for calling today?
Subscription inquiry
What is coveredIs my subscription activeHave a bill but I'm a subscriber, why?Letting you know of a changeOther
Subscription inquiry other notes
Billing office notes
Should be Empty:

Billing Inquiry Form

Credit Card

Billing or insurance coverage question

Providing insurance information

Other billing question

Subscription inquiry