Please Provide Insurance Information

Please Provide Insurance Information

Physicians Ambulance Service, Inc.
4495 Cranwood Parkway,
Cleveland, OH 44128-4003
http://www.physiciansambulance.com

If we have not been provided any insurance information for a patient, a bill can become the patient's responsibility!

Please fill out and return this form, so we may bill the patient's insurance in a timely manner, and avoid patient responsibility. Please submit this form or call our Patient Accounting Office at 216-823-2100.

Patient Information

First Name *

Last Name *

Parent/Guardian Name (if under 21)

Phone # (no spaces) *

Patient Gender

Birth Date * +

Social Security # (no spaces) *

Run or Invoice #

Charge ($)

Do you have insurance? *

Yes - Information Below

No - I need to set up a payment plan

Insurance Information

Medicare #

Medicaid #

Other Insurance Name

Other Insurance Street Address

City

State

Zip

Other Insurance Phone #

Primary Policy Holder Name *

Primary Policy Holder Birth Date * +

Primary Policy Holder E-Mail

Policy #

Group #