Life Force Management - Ambulance Billing Specialists

Submit Insurance Information


In order to process your ambulance claim to your insurance, please provide the following information or call us at:

800-770-4767


Patient Information

* = required
Patient First Name: *
Patient Last Name: *
Last 4 digits of SSN: *
Date of Birth (mm/dd/yyyy): *
Patient Phone Number:
       (777-888-9999)
*
Account ID (on bill):
Community who transported you (on bill):

Please check all that apply:

I do not have insurance to cover the charge. (Please sign below)

The Patient and the Policy Holder are NOT the same person.
I am a Medicare recipient.
I am a Medicaid recipient.
Health Insurance.
Auto Insurance.

I hereby authorize payment be made on my behalf for ambulance services provided to me. I authorize any medical information about me to be released to my insurance carriers and the ambulance companies billing agency to determine benefits payable for related services now and in the future.

I acknowledge, that by entering my name below, that this has the same force of an actual signature.

Signature: *
Date: 09/26/2017