Ablaze, Inc. - EMS, Medical & Fire Rescue Billing Service

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Name	Account Number
Address	Date of Service
City	SSN
State	Home Telephone
Zip Code	Work Telephone

Primary Insurance	Secondary Insurance
Medicare Medicaid	Medicare Medicaid
Other	Other

*Do not fill in information in yellow block for Medicare or Medical/Medicaid.*

Policy #	Policy #
Group #	Group #
Address	Address
City	City
State	State
Zip Code	Zip Code
Phone #	Phone #

Primary Physician	Physician Telephone
Is the patients condition work related (current or previous)?		Yes No
Is the patients condition related to an auto accident?		Yes No



By submitting this form you are authorizing the release of any medical information necessary to process the above account and any future trips. Additionally, you are requesting payment of government benefits for this and future trips.