Submit Insurance Information

Please provide us with your insurance information below. All information provided on this page is encrypted for secure transmission to our servers.

Ambulance Service Transport By (Not Comstar) (required)

Date of Service(required)

Invoice/Run Number(required)

Patient Name(required)

Patient Date of Birth(required)

Is patient under 18 or have an legally assigned guardian? (required)

Parent or Guardian name(required)

Parent or Guardian address(required)

Patient Social Security Number(required)

Patient Address(required)

Patient Phone Number(required)

Email(required)

Was ambulance transport the result of an auto or other accident?

Carrier Name

Carrier Address

Policy Number

Claim Number

Do you have Medicare Coverage?

Carrier Name

Carrier Address

Medicare Subscriber Number

Do you have Medicaid Coverage?

Carrier Name

Carrier Address

Medicaid Subscriber Number

Do you have Another Health Insurance Coverage?

Carrier Name

Carrier Address

Subscriber Number

Do you have a secondary health insurance coverage?

Carrier Name

Carrier Address

Subscriber Number

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