Patient Name:_______________________________Run/Vehicle No:______________Date:___________ Street Address:__________________________________________________________________________ City:______________________________________State:____________________Zip:________________ Phone:_(_______)________________________Date of Birth:______________________Male / Female Race: W - B - O Social Security Number:_________________________________ Medicare:________________________________Medicaid:_______________________________________ Employer:______________________________Address:__________________________________________ City:_________________________State:_____Zip:_______________ Phone:_____________________ Insurance Company:_________________________ Address:_____________________________________ City:_________________________State:_____Zip:_______________ Phone:_____________________ Policy #_______________ Group #______________ Responsible Party: (if other than patient):______________________________________________ Relationship to Patient: Self - Spouse - Child - Other Billing Address (if other than above )___________________________________________________ City:_____________________________________State:____________________Zip:_________________ Work Related: Y-N Accident:Y-N MVA: Y-N ALS vehicle: Y-N Round Trip: Y-N Transported From: [ Residence [ Scene [ Nursing Home Other_______________________________________ Transported To:____________________________________________Loaded Miles:_________________ Chief Complaint/probable diagnosis_______________________________________________________ Past History:____________________________________________________________________________ Check all Special Services Performed and abnormal conditions
To justify ambulance transport we ***MUST MUST MUST*** prove that the patient could not be transported by Automobile/Van/Wheelchair if these were available.
The undersigned agrees to: Œ Release all information for filing claims; If assignment is accepted, reimbursement is directly to the ambulance company; Ž if Medicare, Medicaid, Insurance rejects due to medical necessity, eligibility, or other reasons, that the patient is responsible for payment; if legal/collection agencies are required, patient is responsible for fees. Patient/Responsible Party___________________________________ Medic 1___________________________________ EMT-P EMT-I EMT-B (circle one) Medic 2___________________________________ EMT-P EMT-I EMT-B (circle one) Medic 3___________________________________ EMT-P EMT-I EMT-B (circle one)
Check all that apply -- required in Alabama -- helpful in all states
Proposed
HCFA Diagnoses Listed on Federal Register
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