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.
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.