Patient Inquiry Form
This is a HIPAA and Red Flag Secure and Compliant contact.

(You will need the invoice you received to complete this form.)

*Required fields
*Patient First Name:

*Patient Last Name:







Please look at the top of your invoice and enter the following information.

Ambulance Service Name:

Run #:

*Date of Service:

Membership or Subscription with the Ambulance Service permits third party insurance billing. Please review the message at the bottom of your invoice. This message will advise you of the status of your account. We look forward to hearing from you regarding your account and will be happy to answer your questions.


*Please enter the following text:

Submitting this form acts as a digital signature and your authorization for this transaction.