Medical Insurance Form

Medical Insurance Form

Ambulance Services
You are electing to submit your Health Insurance information via our HIPAA Compliant portal. Doing so allows our team to submit your Ambulance claim on behalf of the EMS agency that treated &/or transported you or your dependant.

If you are submitting Automobile Insurance information, please be sure to check the AUTO box and include your adjuster if known.

If you are submitting Worker's Comp information, we apologize that we did not have this information initially, and request you check the WORK COMP box and include your adjuster, if known.

For health insurance, please check the HEALTH box and include all applicable insurances.
Name of Ambulance Service that treated/transported patient:
Account Number listed on Statement
Patient Information
Patient Name*

First NameLast Name
Is Patient a Minor?

NoYes
Parent Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email
example@example.com
Email and Text Communication Consent – By signing, I allow EMS staff to communicate with me about my ambulance bill using electronic mail (Email) and/or text message (SMS) communication. I understand that Email and text messages are not private or secure; can be altered or forged; forwarded without my permission (either on purpose or by mistake) and if forwarded, may no longer be protected by HIPAA privacy rules; backup copies may exist even after deletion; and copies of all Email and text communications becomes part of my medical and/or billing record and may be used in court cases whether or not the information relates to my care and treatment. I request that EMS billing department send text messages to the mobile number provided and/or Email to the email address provided. I understand my wireless carrier may charge me for such messages. I understand EMS billing department does not receive text message replies to statement notice texts, and I will not receive a reply from EMS if I try to respond to a statement notice text. EMS billing provides this Email/Text alert service as a convenience to its patients in an effort to expedite communication regarding an ambulance bill. I understand I will need to complete a new Email and Text Message Communication Consent if I would like to be contacted at a different number or email address. Revocation/Stop/Quit – I understand that I may withdraw or cancel this authorization at any time by sending written notification to EMS billing. Withdrawal will not apply towards Emails or text messages sent before the written notice is received.
Date of Birth*

MonthDayYear
Date
Gender as per Insurance
Insurance TYPE*

HEALTHAUTOWORK COMP
Insurance Information
Primary Insurance Co*
Policy No*
Group No*
Primary Insurance Phone No*
Subscriber's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Subscriber's Relationship to Patient*
Secondary Insurance Co
Policy No
Group No
Secondary Insurance Phone No
Subscriber's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Subscriber's Relationship to Patient
Automobile Information
Name of Insured Party

First NameLast Name
Name of Insurance*
Claims Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Insurance Rep*

First NameLast Name
Rep Phone Number*
Claim Number issued by Adjuster:*
Policy Number
Worker's Comp Information
Date of Injury*

MonthDayYear
Date
Insurance Name*
Claims Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Claim Number*
Claim Adjuster's Name*

First NameLast Name
Claim Adjuster's Phone
Please enter a valid phone number.
Employer Name*
Employer Phone*
Please enter a valid phone number.
Employer Contact*

First NameLast Name
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Notes
Should be Empty:

Medical Insurance Form

Patient Information

Insurance Information

Automobile Information

Worker's Comp Information