In order to process your ambulance claim to your insurance, please provide the following information or call us at:
Please check all that apply:
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.
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