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IMPORTANT!
Before completing the
secure form
, please make sure you have the following information from your insurance company: Group Number, ID Number, Auth Number.
*
Required Field
CUSTOMER INFORMATION
Are you a current subscriber?
*
Yes
No
Please call 610-398-0239 Ext. 525 to find out how you can receive discounts by becoming a subscriber.
Name (Last, First, Middle)
*
Social Security Number
*
-
-
Sex
*
Female
Male
Date of Birth (mm/dd/yyyy)
*
Age
*
Weight (lbs)
*
INSURANCE INFORMATION
Guarantor Name
*
Guarantor Telephone Number
*
Guarantor Email Address
*
Guarantor Street Address
*
Guarantor City
*
Guarantor State
*
Pennsylvania
No State or Province
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Pacific
Armed Forces Europe
Armed Forces Americas
Guarantor Zip
*
Primary Insurance Company Name
*
Check this box if you do not have insurance. Payment will be required at time of confirmation.
Group Number
*
ID Number
*
Auth Number
Secondary Insurance Company Name
Group Number
ID Number
Auth Number
Is this a Skilled Nursing Facility (SNF)?
*
No
Yes
Do you have Medicare Part A?
*
No
Yes
Medicare Number
Do you have Medicaid or Medical Assistance?
*
No
Yes
Medicaid/Medical Assistance Number
PRIMARY CARE PHYSICIAN
First Name
*
Last Name
*
Telephone Number
*
TRANSPORTATION INFORMATION
If transporting from address is a facility, please list name of facility
If doctors office, please include doctor's name and suite number
Transporting From Street Address
*
Transporting From Street Address 2
Transporting From City
*
Transporting From State
*
Pennsylvania
No State or Province
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Pacific
Armed Forces Europe
Armed Forces Americas
Transporting From Zip
*
Transporting To Street Address
*
Transporting To Street Address 2
Transporting To City
*
Transporting To State
*
Pennsylvania
No State or Province
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Pacific
Armed Forces Europe
Armed Forces Americas
Transporting To Zip
*
Receiving Facility Telephone
*
Type of Call
*
Ambulette
Basic Life Support (BLS)
Advanced Life Support (ALS)
Wheelchair
Medi-Car
If requesting a wheelchair transport, do you have your own chair?
*
No
Yes
Starting
Transport Date (mm/dd/yyyy)
*
Is this recurring?
*
No
Yes
Repeats
*
Daily
Every weekday (Monday to Friday)
Every Monday, Wednesday, and Friday
Every Tuesday and Thursday
Weekly
Monthly
Yearly
Repeat Every
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
days
Repeat on
*
S
M
T
W
T
F
S
Repeat by
*
day of the month
day of the week
Ends
*
Never
After
occurrences
On
Pickup Time (h:mm am/pm)
*
Appointment Time (h:mm am/pm)
*
Return Time (h:mm am/pm)
*
Medical Reason for Transport
*
Do you require oxygen during transport?
*
No
Yes
Number of steps at pick up address
*
Can you go up and down the steps on your own?
*
No
Yes
READ THOROUGHLY BEFORE SIGNING
BY TYPING NAME BELOW I certify that all data provided on this application is true and accurate.
Signature
*
Date
*
Enter the code you see above
*
(Case Sensitive)