Insurance Authorization Form

Please Provide Primary and Secondary Insurance Information Below

Commercial Insurance

Including Secondary Insurance, Auto Insurance (if auto related), Workman's Compensation (if work related), HMO and PPO

Primary Insurance Information

Secondary Insurance Information

PLEASE READ the following documentation before providing your signature.


I request that payment of authorized Medicare, Medical Assistance, or other insurance benefits be made on my behalf to the ambulance service. I authorize and direct any holder of medical information or documentation about me to release to the Centers for Medicare and Medicaid Services and its carriers and agents, as well as to the ambulance service and its billing agents and any other payers or insurers, any information or documentation needed to determine these benefits or benefits payable for any services provided to me by the ambulance service now or in the future, when applicable. I agree to immediately remit to the ambulance service any payments that I receive directly from any source for the services provided to me and I assign all rights to such payments to the ambulance service. Additionally, I authorize the ambulance service to perform all necessary and appropriate insurance claim appeals when my insurance carrier inappropriately processes my claim(s). I understand that payment for this service or item may be from Federal and State Funds, and that any false claims, statements, or documents, or concealment of material may be prosecuted under applicable Federal and State laws.

The paragraph below DOES NOT apply to Medical Assistance Recipients. The paragraph below does not replace the required Advance Beneficiary Notice required in specific circumstances by Medicare. By signing this form I authorize that the signer is a POA, legal guardian, relative or person who receives government benefits on behalf of the patient, an agency or institution that furnished care, service or assistance to the patient or a person or relative who arranges treatment or handles the patients affairs.

I furthermore understand and agree to be financially responsible to the ambulance service for all charges not covered under my insurance subject to the protections afforded to me by either my membership agreement or all State and/or Federal reimbursement programs and regulations. I agree that if payment is not made by my insurance company or applicable third party payer, I will be responsible for payment to the ambulance service.

I also acknowledge that I have received a copy of the Ambulance Notice of Privacy Practices. A copy of this form is as valid as the original. Notice of Privacy Practices

Check this box if you acknowledge the previous field to represent your actual signature, and that you have read and understand the above terms.