PayMyAmbulanceBill.com
Insurance
Patient Data
Patient Name:
E-mail Address:
Ambulance Company Name:
Date of Transport:
Account Number (if known):
Insurance Information
Medicare:
    Medicare Number: Date of Birth:
Medical Assistance:
    MA Identification Number:
Commercial/Motor Vehicle/Workers Comp:
  Primary Insurance Information Secondary Insurance Information
   
Insurance Company Name:
Mailing address (if on card):
Phone Number (if on card):
Policy Holder Name:
Policy Number:
Insurance Company Name:
Mailing address (if on card):
Phone Number (if on card):
Policy Holder Name:
Policy Number:
PLEASE READ THE FOLLOWING INFORMATION BEFORE PROVIDING YOUR ELECTRONIC SIGNATURE
BILLING AUTHORIZATION

I request that payment of authorized Medicare, Medicaid, or any other insurance benefits be made on my behalf to this Ambulance Service for any services provided to me by this Ambulance Service now, in the past, or in the future. I understand that I am financially responsible for the services and supplies provided to me by the Ambulance Service, regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to the any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to Ambulance Service. I authorize Ambulance Service to appeal payment denials or other adverse decisions on my behalf without further authorization. I authorize and direct any holder of medical information or other relevant documentation about me to release such information to Ambulance Service and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by ABC, now, in the past, or in the future.

A copy of this form is as valid as an original.
Beneficiary Signature (type your full name):     Date:     
2017 PayMyAmbulanceBill.com. All rights reserved.
Website Design, Development and Hosting by ONE 2 ONE.