EMS Billing Inquiries

2. 

3. EMS Billing Inquiries
   This form is used to communicate with Fire Department Personnel to request information regarding your EMS Billing for emergency ambulance transports.

   This form is used to communicate with Fire Department Personnel to request information regarding your EMS Billing for emergency ambulance transports.

5. First Name*

6. Last Name*

8. Address*

10. City*

11. State*

12. Zip Code*

14. Phone Number*

15. Email Address*

19. What was the date of the emergency transport?

21. Please list the Patients Name and Date of Birth

23. Nature of the complaint / suggestion...

Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field