Insurance Billing Information
for Ambulance Transport

STEP 1

PATIENT
INFORMATION

STEP 2

INSURANCE
INFORMATION

STEP 3

CONFIRM YOUR
INFORMATION

Safe & Secure

If you would like to pay with a credit card or set up a payment plan, please call (800) 244-2345 between 8:30 AM - 7:30 PM CST Monday through Friday.

Information with * is required

RUN NUMBER *    (ex. 12-3456789)
DATE OF SERVICE * (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 * (ex. 630-555-1212)
ALTERNATE PHONE NUMBER (ex. 630-555-1212)
PATIENT BIRTH DATE * (ex. 01/01/2013)
SOCIAL SECURITY NUMBER * (ex. 333-45-6789)
     

Problems or Questions? Please call (800) 244-2345 or email inshelp@andresmedical.com.