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.
*Please use the
link
below to submit
an electronic
signature.
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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Electronically
Complete
Insurance
Information
Use the link
to the right to
complete
insurance
information
online for
billing. You can
also print,
fill, and send
the information
through mail if
you prefer by
using the form
above.
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Electronically
Sign the Patient
Signature Form
If your
signature is
needed for
billing, please
review and
electronically
sign the Patient
Signature Form
using the button
to the right.
This will allow
us to process
your insurance
for
billing.
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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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Levy Information
If you live within
City of Everett Fire Department
boundaries, then, after all insurance(s) have been billed, any balance not covered by your insurance will be paid out of EMS Levy funds. If you are a resident and have no insurance coverage, the EMS Levy will cover your bill. You will continue to receive statements until you have provided us with your insurance information, or you have verified that you have no coverage.
If you live outside of
City of Everett Fire Department
boundaries, you are financially responsible for any portion of your bill not paid by your insurance(s). If you are not a resident and you are uninsured, you are responsible for the total amount of your bill.
If you live within
City of Everett Fire Department
boundaries, then you are considered a resident and there will be a levy message on your billing statement. If you do not see a levy message on your billing statement, this means that you are not considered a resident for ambulance billing purposes.
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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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