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.
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:


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

    This field is not part of the form submission.

27. Submit

* indicates a required field