Welcome
Dear Patient,
Thank you for visiting our Emergency Medical Services web site. The statement you have received is for an ambulance transport provided to you or a family member by
Sample Fire District.
You may find the following information helpful.
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Insurance
Information
Please
check your
invoice/statement
for an
IMPORTANT
MESSAGE
section at the
top. If we do not
have insurance
information, or
if we need a
signature, a
request was
included with
your statement.
If we have
insurance
information, the
insurance
company has been
billed and the
statement
reflects any
remaining
balance that may
be due.
If there is
any other
insurance that
can be billed,
please provide
us with that
information. You
may download and
fill out the
insurance
information form
to the right and
mail, fax or
email a scanned
copy of it to
the billing
service
department.
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Financial Assistance
Financial Assistance is available to those who are eligible. If you or your family's annual income is at or below the national poverty guidelines for this area, an application may be downloaded using the link to the right.
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Consumer Rights
Notice
In
Washington
State, when you
get emergency
care or are
treated by an
out-of-network
provider at an
in-network
hospital or
ambulatory
surgical center,
you are
protected from
surprise billing
or balance
billing for
amounts beyond
patient
responsibility
under your
medical
insurance plan.
Please see your
Consumer Rights
on Balance
Billing in the
document on the
right.
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Payment Options
Credit Card/ACH
transaction
A
processing fee will apply when making payments by credit card or
ACH
transaction. For credit cards, the fee is
2.95% of the invoice amount (Minimum Transaction Amount: $2.00). For
ACH
transactions,
the fee is
$0.85.
(NOTE: You will be asked for information appearing on your invoice/statement, so it should be readily available. Verify that
Sample Fire District
appears in the upper left corner of your invoice/statement.)
- ONLINE: To make an online payment, click the Payment icon to the right.
(NOTE: You must have a valid email address to use the online option)
- PHONE: To make a credit or debit card payment over the phone, contact our Billing Services department at (800) 238-9398.
Check/Money Order
Please mail checks or money orders to:
Sample Fire District
P.O. Box 3510
Silverdale, WA 98383
Other Payment Arrangements
Please contact our Billing Service department at (800) 238-9398 if you wish to make other payment arrangements.
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How to Contact Us
For more information or to make payment arrangements, please contact our billing department at the phone number, fax number or email address provided below:
1) Call our billing service department at (800) 238-9398. Please refer to the account number located on the top section of your statement.
2) Email a response to our request for insurance information form or any questions you may have to the following email address:
Sample@emspatient.com
3) Fax documents to the
Sample Fire District
billing service department:
Fax # (360) 394-7094.
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