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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:
None
Father
Mother
Brother
Sister
Spouse
Child
Grandparent
Grandchild
Other
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.