SIGNATURE AND INSURANCE FORM

Lifetime Authorization for Release of Medical Records and Assignment of Benefits.

 

ADVANCED BENEFICIARY NOTICE

To be used in the event ambulance coverage may not be covered by Medicare.

FACILITY BROCHURE

Information to help facilities in making appropriate decisions for non emergency transpiration.

HIPPA NOTICE OF PRIVACY PRACTICE

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

FAMILY SUPPORT BROCHURE

Information to assist patients and families in making appropriate decisions for non emergency transportation. 

PHYSICIAN'S CERTIFICATION STATEMENT

Physician's Certification Statement (PCS) for non emergency ambulance transportation.

AUTHORIZATION FOR RELEASE OF INFORMATION (ROI)

Document to give permission to use or disclose protected health information.