Ambulance Billing Company - Patient Form (please provide all required information)
For questions please call 877-251-2861 or email
lthomas@ambulancebillingco.com
* Required
Email address
*
Your email
Name
*
Your answer
Address
*
Your answer
Phone Number 999-999-9999
*
Your answer
SSN
Your answer
Birthday mm/dd/yyyy
*
MM
/
DD
/
YYYY
Call Number
*
Your answer
Agency
*
Choose
Anyway Medical Transport
Big Stone Gap
City of Bridgeton
Cresskill Fire Department EMS
Deerfield Twp/Rosenhayn
Englewood EMS
Fairfield Twp Ambulance Service
Fairfield Fire Department EMS
Flemington Raritan First Aid Squad
Great Meadows EMS
Guardwell Ambulance
High Bridge Emergency Squad
Lakeland Emergency Squad
Lebanon Twp Fire Dept EMS
Manville First Aid Squad
Maplewood Fire Dept EMS
Milford Holland Rescue Squad
North Warren EMS
Pattenburg EMS
Springfield First Aid Squad
Upper Saucon Ambulance Corps
Valor Ambulance
Western Monmouth EMS
Whitehouse Rescue Squad
Woodland Fire and EMS
Date of Call
*
MM
/
DD
/
YYYY
Insurance/Payment information
*
Insurance
Credit Card
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