PWW Model AOB Signature Form Version 2 2 2026

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The document is a Sample Ambulance Signature/Claim Submission Authorization Form that outlines the process for patients or their authorized representatives to authorize the submission of claims for ambulance services provided by ABC Ambulance Service. It includes sections for patient signatures, authorized representative signatures, and ambulance crew and receiving facility signatures, along with acknowledgments regarding privacy practices and financial responsibilities.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Patient Name and Transport Date at the top of the form. Ensure accuracy as this information is crucial for processing.
In Section I, if the patient is able, they should sign in the designated area. If a minor, a parent or legal guardian must sign instead.
Review the Privacy Practices Acknowledgment carefully before signing. This confirms that the patient has received necessary privacy information.
If applicable, have a witness sign below the patient's signature if they are unable to sign with their name.
For Section II, complete this only if the patient cannot sign. Describe why they are unable to do so and have an authorized representative sign.
In Section III, if no authorized representative is available, ambulance crew members must complete this section by signing and providing details about the receiving facility.

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Versions	Form popularity	Fillable & printable
2020	4.1 Satisfied (44 Votes)
2014	4.6 Satisfied (52 Votes)

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