Patient Inquiry Form

This is a HIPAA and Red Flag Secure and Compliant contact.

(You will need the invoice you received to complete this form.)

*Required fields

Please look at the top of your invoice and enter the following information.

Membership or Subscription with the Ambulance Service permits third party insurance billing. Please review the message at the bottom of your invoice. This message will advise you of the status of your account. We look forward to hearing from you regarding your account and will be happy to answer your questions.

Submitting this form acts as a digital signature and your authorization for this transaction.