Application EMS InformationEMS Department:Date of Service: Account Number:Patient InformationName:*Date of Birth:* Street Address*Social Security NumberCity, State, Zip*Phone Number:Email* Please provide at least one contact method...Insured Information (if other than patient)Name:Phone Number:Guarantor Information (if applicable)Name:Guarantor Birth Date: Primary Insurance InformationName of Insurance:*Member ID Number*For traditional Medicare (red, white and blue card) this is usually your SSN, with a letter or letter & number, at the end. For Medicaid, this is the 12-digit billing number on your cardGroup Number:Claim Street Address:City, State, Zip:Secondary Insurance InformationName of Insurance:*If no secondary insurance please type N/A in all required secondary fields.Member ID Number:*For traditional Medicare (red, white and blue card) this is usually your SSN, with a letter or letter & number, at the end. For Medicaid, this is the 12-digit billing number on your cardGroup Number:Claim Street Address:City, State, Zip:Auto or Workers Compensation Insurance InformationName of Insurance:Claim Number:Policy Number:Please only provide policy number IF you do not know your claim number...Claim Street Address:City, State, Zip:
