Copyright (c) 2007 Manheim Township Ambulance Association. All rights reserved.

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NOTICE: If you are Medicare and/or Medicaid eligible, you must download and print this form. We are required by law to have a physical signature on file for these two carriers per Federal regulations.

This information will remain on file and shall not be shared with any entity without prior instruction and permission by the policy holder there of. We maintain physical, electronic and procedural safeguards to comply with federal regulations to guard this information.

Personal Info

Name:

Address:

Patient#:

Date of Service:

Date of Birth:

Social Security #:

Family Physician:

Private and/or HMO/PPO/POS:

Name:

Address:

Telephone #:

Policy or ID #:

Group #:

Automobile Insurance Carrier

Name:

Address:

Telephone #:

Policy #:

Claim #:

Manheim Township Ambulance Association 1820 Municipal Drive
Lancaster, PA 17601-4105

Please print and fill out this form and mail it to:

Billing Information

Signature:

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