Insurance Authorization

Patient Name 

Date of Service 

Invoice Number 

Account Number 

Trip Number 

Your Email Address 

Please Provide Primary and Secondary Insurance Information Below

Medicare Number 

Medical Assistance 

Commercial Insurance
(including Secondary Insurance, Auto Insurance – if auto related, Workman’s Compensation – if work related, HMO and PPO)

POLICY #1

Policy Holder’s Name 

Insurance Company name 

Insurance Company Mailing Address

Policy Number 

Group Number 

POLICY #2

Policy Holder’s Name 

Insurance Company Name 

Insurance Company Address

Policy Number 

Group Number 

Payment Information

Card Type—VisaMasterCardAmerican Express

Card Number 

Card Security Code 

Amount To Charge Card 

Cardholder’s Information

Name 

Address 1 

Address 2 

City 

State 

Zip 

Phone 

Expiration Date – Month —010203040506070809101112 Year —20102011201220132014201520162017201820192020

PLEASE READ the following documentation before providing your signature

I request that payment of authorized Medicare, Medicaid, or any other insurance benefits be made on my behalf to Lafayette Ambulance and Rescue Squad Inc. (Lafayette Ambulance), for any services provided to me by Lafayette Ambulance now or in the future. I understand that, unless I am a Pennsylvania Medical Assistance Recipient, I am financially responsible for the services provided to me by Lafayette Ambulance, 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 Lafayette Ambulance, 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 Lafayette Ambulance. I authorize Lafayette Ambulance to appeal payment denials or other adverse decisions on my behalf without further authorization. I authorize and direct any holder of medical information or documentation about me to release such information to Lafayette Ambulance and its billing agents, and/or the Centers for Medicare and Medicaid Services and its carriers and agents, and/or any other payers or insurers as may be necessary to determine these or other benefits payable for any services provided to me by Lafayette Ambulance, now or in the future. A copy of this form is as valid as an original.

Privacy Practices Acknowledgment: by signing below, I acknowledge that I have received the Lafayette Ambulance Notice of Privacy Practices. I further understand my privacy rights concerning protected health information (PHI) about me and I agree to consent fully to the uses and disclosures of PHI by Lafayette Ambulance as more fully described in the Lafayette Ambulance Notice of Privacy Practices.

Signature of Patient 

Check this box if you acknowledge the previous field to represent your actual signature, and that you have read and understand the above terms

Relationship to Patient 

Date of Signature