Ambulance Service

1-309-524-5300

Please complete the following information for billing purposes. If you do not have insurance coverage, please contact our office to make payment arrangements.

PATIENT NAME

ACCOUNT #

DOS:

IS THIS CLAIM DUE TO:

Auto/Liability/Work Comp Ins Name

Auto/Liability/Work Comp Claim Number

Auto/Liability/Work Comp Mailing Address

Auto/Liability/Work Comp Contact Phone Number

Primary Health Insurance Name

Member ID

Group # (If listed)

Insurance Contact Phone #

Insurance Mailing Address: (Listed on card)

Secondary Health Insurance Name

Member ID

Group #

INSURANCE ADDRESS

Serving: Illinois and Iowa