City of Valdez Insurance Information and Signature Request Form

Patient Full Name:*

Please enter your full legal name as it appears on your insurance card to ensure accurate processing.

Patient Phone Number:*

Please enter a valid phone number.Format: (000) 000-0000.

Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient ID:

Your Patient ID can be located on your invoice/statement.

Patient Social Security Number:

Patient Birth Date:*

MonthDayYear

The bill you have received is for ambulance services provided to you or your dependent by City of Valdez. You are financially responsible for these charges. Your insurance may cover all or part of these charges. If it is convenient for you to send copies of the front and back of your insurance card(s), please do so, as it will provide the necessary information for billing. Please complete this form and return it to us promptly. If you have any questions or wish to provide this information to us directly, contact Billing Services at (360) 394-7010 or (800) 238-9398 Monday through Thursday from 8:00 AM to 6:00 PM, and Friday from 8:00 AM to 5:00 PM Pacific Time.

I DO have insurance applicable to this service.I do NOT have any insurance applicable to this service.

PRIMARY INSURANCE

POLICY HOLDER INFORMATION

SelfSpouseDependent

I DO have secondary insurance applicable to this service.I do NOT have secondary insurance applicable to this service.

SECONDARY INSURANCE

POLICY HOLDER INFORMATION

SelfSpouseDependent

AutoWork

I DO have auto or worker's insurance applicable to this service.I do NOT have any auto or worker's insurance applicable to this service.

AUTO OR WORKER'S INSURANCE

POLICY HOLDER INFORMATION

SelfSpouseDependent

We must have your signature on file in order to bill your insurance(s). Please sign below.

City of Valdez, hereinafter referred to as Provider

Patient Full Name:*

Patient Transport Date:*

MonthDayYear

Yes, I authorize the Provider to apply this signature to all outstanding transports under the same billing entity.

I authorize the submission of a claim for payment to Medicare, Medicaid, or any other payor for any services provided to me by the Provider now, in the past, or in the future, until such time as I revoke this authorization in writing.
I understand that I am financially responsible for the services and supplies provided to me by the Provider regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance.
I agree to immediately remit to the Provider any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to the Provider.
I authorize the Provider to appeal payment denials or other adverse decisions on my behalf without further authorization.
I authorize and direct any holder of medical information or other relevant documentation about me to release such information to the Provider and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by the Provider now, in the past, or in the future. A copy of this form is as valid as an original.

Signature* Patient Signature (or Authorized Representative)

Printed Full Name*

Date*

MonthDayYear

Yes, I am signing as an authorized representative on behalf of the patient.

If signing on behalf of the patient, please indicate relationship