Insurance Information

Insurance Information

Date of Transport:

Call # (if known):

Patient's Information

Patient's Name:	DOB:
	SS #

Guarantor's Information

Guarantor's Name:			Relationship to Pt.:
			Phone # ( )
Guarantor's Address:	Street:	City:		State:	Zip:

Primary Insurance Information

Primary Ins. Name:			Policy #
			Group #
Primary Ins. Address:	Street:	City:		State:	Zip:
Insured's Name:

Secondary Insurance Information

2^nd Ins. Name:			Policy #
			Group #
2^nd Ins. Address:	Street:	City:		State:	Zip:
Insured's Name:

Employer:	Voucher Approved [ ]Y [ ]N
	Phone # ( )

Medicare #

Medicaid #

Release for Medical Billing/Insurance/Medicare Notice

Lifetime Signature Authorization
I hereby authorize the release of any medical records or other information that is necessary to process any claims for medical or other Insurance benefits. I understand that I have an obligation to pay _________________________________ Ambulance Service for the services and supplies provided regardless of any deductible, co_payments, or other variations in individual insurance programs. This is a direct assignment of my rights and benefits under my insurance policy. If I have Medicare/Medicaid, _________________________________ Ambulance agrees to accept assignment, and I authorize ___________________________________ Ambulance to bill my carrier (providing any and all documentation requested) for whatever benefits I am entitled.

To Medicare patients - Federal Law requires that we notify you when services to be provided may not be covered by them because it may not meet their guidelines. We are of the opinion, that the ambulance transportation on this date may not be covered if: 1) Patient is transported to a Physician's office, 2) The patient is transported beyond the nearest appropriate facility, 3)Transportation is for the convenience of the patient or the physician, 4)If the physician does not sign a physician certification at the time of transportation or within 48 hrs. on all non-emergency transports. This document serves as notice that if Medicare denies payment for this service, we will hold you responsible for payment.

I further authorize the release of any medical information to enable proper completion of the quality improvement process for _________________________ Ambulance Service. I further give my physician, my nursing staff, and any nursing facility involved with my care permission to disclose information to the above named ambulance service, information for the express purpose of billing my claim to my carrier. Any information about my insurance or health is to be held in strict confidence for the sole purpose as noted.

Signature of Patient, Legal Guardian, Healthcare Surrogate___________________________________________________________