Ambulance Billing Authorization Form 2025

1. Click ‘Get Form’ to open the Ambulance Billing Authorization Form in the editor.
2. Begin by entering the patient's name and transport date at the top of the form. Ensure accuracy as this information is crucial for billing purposes.
3. In Section I, if you are the patient, sign your name where indicated. If you are unable to sign, a witness should also sign below your mark.
4. If you are signing on behalf of the patient, complete Section II. Provide an explanation for why the patient cannot sign and ensure that you check one of the authorized representative options.
5. In Section III, if applicable, have an ambulance crew member complete their statement confirming that no authorized representative was available at the time of service.
6. Finally, ensure all signatures are dated and any additional documentation is attached as required before submitting.

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