Please contact me to discuss payment

You have received a bill that should look similar to the one below. Please use the information from YOUR bill in the fields below.

Statement Sample

Fields marked with an (*) are required.

Step 1: Bill Details

Ambulance Name:(*)
Please enter the Ambulance Name

Date of Service:(*)
Please enter date of service from your invoice.

Step 2: Patient Information

First Name:(*)
Please enter patients first name.

Last Name:(*)
Please enter patients last name.

Address:(*)
Please enter patients street address.

Address 2:
Invalid Input

Apt, Suite #

City:(*)
Please enter patients city

State:(*)
Please select patients state

Zip Code:(*)
Please enter patient zip code

Phone Number:(*)
Please enter patient phone number.

Date of Birth:

Month:(*)
Please select month

Day:(*)
Please select day

Year:(*)
Please enter DOB year

Last 4 of Social Security No:

Email Address:(*)
Please enter your email address.

Your email address will be used to verify any missing information and send you a copy of the form you are submitting.

Comments/Special Instructions
Invalid Input

By typing my name, I, the undersigned, certify that I am signing this document as the person whose signature is required, or as agent of the person(s) whose signature would be required who has authorized me to sign this document on his/her behalf, or in both capacities. I further certify that I have completed all required fields, and that the information in this document is true and correct and in compliance with the applicable chapter of Minnesota Statutes. I understand that by signing this document I am subject to the penalties of perjury as set forth in Section 609.48 as if I had signed this document under oath.

Authorized Signature:(*)
Invalid Input

(please enter your first name, middle initial and last name)

A typed name in the space for the signature is legally considered a signature under Minnesota Statues, Sections 325L.02, clause (h) and 325L.07, clause (d).

 

Fields marked with an (*) are required.

Step 3: Contact Information

First Name:(*)
Please enter your first name

Last Name:(*)
Please enter your last name

Phone:(*)
Please enter your phone number

Alternative Phone:
Invalid Input

Best time to call:(*)

Please select

(select all that apply)

Best day to call:(*)

Please select

(select all that apply)

Questions? Contact (866) 780-0184

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