Insurance Information

Insurance Claims Information Form

By providing us with the most up-to-date and accurate insurance information, you can help us ensure that the patient does not recieve a bill when it should be going to the insurance company.

Please fill out the form below and click submit:

Ambulance Service:

Date of Service (mm-dd-yy):

Call # (reference invoice):

Patients First Name :

Patients Last Name :

Parent or Responsible Party :

Social Security # (000-00-000) :

Mailing Address :

City:

State:

Zip Code :

Telephone # of PT or Responsible Party :

E-mail:

Pt. Medicare # :

Pt. Medicaid # :

Commercial Insurance:

Commercial Insurance Policy #:

Auto Insurance Company :

Auto Insurance Policy # :

Download the Form

You can also click on the link below and fill out the form to provide us with your insurance information. All fields must be filled out . Write "NA" in any fields in which you are unable to provide information.

When you have completed filling out the sheet, you may submit it electronically or print it out to mail to our office and/or to keep a copy for your records.

Insurance Information Form