Ambulance Billing Services Claim Helper

Patient Name
Address
City, State, Zip
Phone Number
E-mail Address
Name of Ambulance Service
Date of Service (on bill)
Call Number (found on ambulance bill)
Patient Date of Birth
Social Security Number
Medicare Number, if Medicare recipient
Medicaid Number, if Medicaid recipient
Health Insurance Company
Policy Number
Auto Insurance Company, if auto accident
Auto Policy Number, if accident
Claim Number from auto insurance
Additional Information or comments: