Your National Reimbursement Specialists Providing Innovative EMS and Emergency Response Billing Solutions Since 1989.

Insurance Information for Ambulance Transportation

	Required fields are denoted by . Please provide your account information:*
	Account Number:	(Please enter the Account Number located in the upper right corner of your statement.)
	Provider of Service:


	Please provide the following contact information:
	*Patient Last Name:
	*Patient First Name:
	Email Address
	*Incident Date:
	(Enter SS# as XXX-XX-XXXX)
	Work Phone:
	*Home Phone:
	Reason for Transport:	Illness Auto Accident Workplace Accident Other:
	Auto Insurance Name:
	Auto Insurance Address:
	Auto Insurance Phone:
	Auto Insurance Adjustor Name:
	Auto Insurance Claim #:
	Workman's Comp Carrier Name:
	Workman's Comp Address:
	Workman's Comp Phone:
	Workman's Comp Adjustor Name:
	Workman's Comp Claim #:
	Medicare #:
	Medicaid #:


Please provide your Primary Insurance Information:		Please provide your Secondary Insurance Information:
Primary Insurance Name:		Secondary Insurance Name:
Address 1:		Address 1:
Address 2:		Address 2:
City/State/Zip:		City/State/Zip:
Phone #:		Phone #:
Identification#:		Identification #:
Group:		Group:
Subscriber Name:		Subscriber Name:
Subscriber's relationship to patient:	Self Spouse Mother Father Other - specify (such as Step Parent)	Subscriber's relationship to patient:	Self Spouse Mother Father Other - specify (such as Step Parent
Subscriber DOB:		Subscriber DOB:

Please provide any additional information:



Please ensure the correctness of the form before submitting. Please wait for a confirmation page. Thank You.

Please call 800 926 6985 for Information

Please provide your account information: