Patient Insurance Form
To help us file a claim with your insurance carrier, please complete the form below and press the 'Submit' button.

*Required fields
Patient Information

*Run Number:

*Date of Service:

*Patient First Name:

*Patient Last Name:

Date of Birth:

*Phone:


Patient Representative

First Name:

Last Name:

Relationship to Patient:

Other:
Phone Number:


Insurance Information

Medicare Number:

Medicaid Recipient ID:


Primary Health Insurance

Primary Insurance Name:

Primary Insurance Street:

Primary Insurance Apt., Suite, etc.:

Primary Insurance City:

Primary Insurance State:

Primary Insurance Zip:

Insurance Phone Number:

ID Number:

Group/Plan Number:

Name of Insured:


Secondary Health Insurance

Secondary Insurance Name:

Secondary Insurance Street:

Secondary Insurance Apt., Suite, etc.:

Secondary Insurance City:

Secondary Insurance State:

Secondary Insurance Zip:

Insurance Phone Number:

ID Number:

Group/Plan Number:

Name of Insured:


Additional Information

The ambulance service provided was the result of an employee accident
The ambulance service provided was the result of an automobile accident
Patient is a member of an ambulance company

Comments/Special Instructions:

*Please enter the following text:



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