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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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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Payment Options
Check/Money Order
Please mail checks or money orders to:
Sample Fire District
P.O. Box 3510
Silverdale, WA 98383
In-Person at
City Hall
Payments may be made in person at City Hall. Please include
the top tear-off portion of the billing invoice/statement you received.
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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