Insurance Billing Information for Ambulance Transport

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For customer service or payment plans, please call 877-618-0943 between 8:30am - 7:30pm CST, M-F (except Holidays)

STEP 1

PATIENT
INFORMATION

STEP 2

Electronic Signature

STEP 3

INSURANCE
INFORMATION

STEP 4

CONFIRM YOUR
INFORMATION

Safe & Secure

Information with * is required

RUN NUMBER *				(MHIL-2017-001001:01)
Enter the number exactly as it shown on the invoice, with any hyphens or colons
DATE OF SERVICE *	Month	Date	Year	(ex. 01/01/2013)
Your Run Number and Date of service can be found on your invoice.
PATIENT INFORMATION
FIRST NAME *
LAST NAME *
ADDRESS 1 *
ADDRESS 2
CITY *
STATE *				(IL)
ZIP CODE *				(ex. 60101)
PRIMARY PHONE NUMBER *	Area Code	First 3	Last 4	(ex. 630-555-1212)
ALTERNATE PHONE NUMBER	Area Code	First 3	Last 4	(ex. 630-555-1212)
PATIENT BIRTH DATE *	Month	Date	Year	(ex. 01/01/2013)
SOCIAL SECURITY NUMBER	First 3	Middle 2	Last 4	(ex. 333-45-6789)

GUARANTOR INFORMATION Guarantor is the insurance policy holder. Only required if guarantor is not the patient.
FIRST NAME
LAST NAME
ADDRESS
PHONE NUMBER	Area Code	First 3	Last 4	(ex. 630-555-1212)

Problems or Questions? Please call (877) 618-0943