Please submit to my insurance

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).

 
Step 3: Insurance Information

Insurance Type:*
Please select insurance type

Health Insurance Type:
Invalid Input

Medicare ID:*
Invalid Input

(please include all letters and numbers)

Name:*
Invalid Input

(exactly as it appears on your medicare card, not "Medicare Name")

Subscriber ID:*
Invalid Input

State:*
Invalid Input

Insurance Company Name:*
Invalid Input

Insurance Company Address:*
Please enter insurance companies address

Insurance Company City:*
Please enter insurance companies city

Insurance Company State:*
Please Select

Insurance Company Zip:*
Please enter insurance companies zip code

Policy Holder Name:*
Invalid Input

Policy Number:*
Invalid Input

(please include all letters and numbers)

Group Number:*
Invalid Input

Insurance Company Name:*
Invalid Input

Insurance Company Address:*
Please enter insurance companies address

Insurance Company City:*
Please enter insurance companies city

Insurance Company State:*
Please Select

Insurance Company Zip:*
Please enter insurance companies zip code

Claim Number:*
Invalid Input

(please include all letters and numbers)

Adjustor Name:*
Please enter Adjustors Name

Adjustor Phone Number:*
Please enter Adjustors Phone Number

Insurance Company Name:*
Please enter insurance company name

Insurance Company Address:*
Please enter insurance companies address

Insurance Company City:*
Please enter insurance companies city

Insurance Company State:*
Please Select

Insurance Company Zip:*
Please enter insurance companies zip code

Claim Number:*
Please enter claim number

(please include all letters and numbers)

Adjustor Name:*
Please enter name

Adjustor Phone:*
Enter adjustors phone number

Insurance Company Name:*
Invalid Input

Insurance Company Address:*
Please enter insurance companies address

Insurance Company City:*
Please enter insurance companies city

Insurance Company State:*
Please Select

Insurance Company Zip:*
Please enter insurance companies zip code

Insurance Company Phone:*
Enter phone number

Claim Number:*
Invalid Input

(please include all letters and numbers)

Adjustor Name:
Please enter name

Adjustor Phone:
Enter adjustors phone number

Provide Additional Insurance:*
Invalid Input

Insurance Company Name:
Invalid Input

Insurance Company Address:
Please enter insurance companies address

Insurance Company City:
Please enter insurance companies city

Insurance Company State:
Please Select

Insurance Company Zip:
Please enter insurance companies zip code

Insurance Company Phone:
Enter phone number

Policy Holder Name:
Invalid Input

Policy Number:
Invalid Input

(please include all letters and numbers)

Group Number:
Invalid Input

Claim Number:
Invalid Input

(please include all letters and numbers)

Adjustor Name:
Please enter name

Adjustor Phone:
Enter adjustors phone number

Authorization for Billing / Release of Patient Information / Assumption of Financial Responsibility: I request that payment of authorized Medicare/Medicaid and/or other insurance benefits be made to the pre-hospital care provider ("Provider") for any services furnished to me. I authorize any holder of hospital or medical information about me to be released to the Provider, Centers for Medicare and Medicaid Services, and/or my insurance carriers and their agents, including any other information needed to determine these benefits or other benefits payable for related services. I permit a copy of this authorization to be used in place of the original. I understand this authorization may be used by the Provider for all services furnished in the future until such time as I revoke this authorization in writing. I agree to assume full financial responsibility for payment of all charges not covered by my insurance carrier as well as any collection costs and/or attorney's fees as allowed by law.

Patient/Guarantor Signature:*
Invalid Input

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

Relationship to Patient:*
Please enter relationship to patient

Date of Signature:*
Invalid Input

Questions? Contact (866) 780-0184

Privacy Policy | Terms and Conditions | TransMedic

Copyright © EMS Patient Pay & TransMedic. All Rights Reserved.