Patient Transport Insurance Information Form

To process your claim, please fill out the form below with your insurance information. Only fill fields that are applicable to your coverage.

EMS Information
EMS Department:
Date of Service:
Account Number:
Patient Information
Name:*
Date of Birth:*
Street Address*
Social Security Number
City, 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 Information
Name 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 card
Group Number:
Claim Street Address:
City, State, Zip:
Secondary Insurance Information
Name 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 card
Group Number:
Claim Street Address:
City, State, Zip:
Auto or Workers Compensation Insurance Information
Name 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:

Medicount maintains physical, electronic and procedural safeguards to guard your nonpublic personal information. Our operational and data processing systems are contained in a secure environment and that environment is access-controlled. To secure sensitive communications between your computer and our web servers, we have implemented digital certificates and enabled strong, RSA1024-bit, encryption. We use secure sockets layer, SSL, security protocol to protect all exchanges of information via our web pages that are considered private or confidential.

Patient Transport Insurance Information Form

EMS Information

Patient Information

Insured Information (if other than patient)

Guarantor Information (if applicable)

Primary Insurance Information

Secondary Insurance Information

Auto or Workers Compensation Insurance Information