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 Transported By (Not Comstar) (required)

Date of Service(required)

Invoice/Run Number(required)

Patient Full Name(required)

Patient Date of Birth(required)

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

Parent or Guardian Name(required)

Parent or Guardian Address (Street Address or PO Box, City, State, Zip)(required)

Patient Address (Street Address or PO Box, City, State, Zip)(required)

Patient Phone Number(required)

Email(required)

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

Insurance Name

Insurance Address

Policy Number

Claim Number

Do you have Medicare Coverage?

Insurance Name

Insurance Address

Medicare ID Number

Do you have Medicaid Coverage?

Insurance Name

Insurance Address

Medicaid ID Number

Do you have another health insurance coverage?

Insurance Name

Insurance Address

Insurance ID Number

Do you have a secondary health insurance coverage?

Insurance Name

Insurance Address

Insurance ID Number

This field should be left blank

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