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Ambulance Billing Lifetime Authorization and Privacy Acknowledgment Form

Ambulance Billing Lifetime Authorization and Privacy Acknowledgment Form 2025

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The document is an Ambulance Billing Lifetime Authorization and Privacy Acknowledgment Form for patients receiving services from Coastal Health Systems of Brevard, Inc. It outlines the patient's request for insurance payments, their financial responsibility for services, authorization for CHSB to appeal payment denials, and the release of medical information necessary for billing. It also includes a notice regarding Medicare/Medicaid coverage limitations and requires patient or authorized representative signatures.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How to bill for ambulance services?

Use HCPCS code A0427 (ambulance service, advanced life support, emergency transport, level 1 [ALS1-emergency]) or A0429 (ambulance service, basic life support, emergency transport [BLS-emergency]) when billing for response to an emergency (911) call.

What is the CPT code for an ambulance?

Procedure Codes and Modifiers Procedure CodeDescription A0429 Ambulance service, basic life support, emergency transport (BLS-Emergency) A0429 Ambulance service, basic life support, emergency transport (BLS-Emergency) A0430 Ambulance service, conventional air services, transport, one way (fixed wing)23 more rows

How much does a 30 minute ambulance ride cost?

What Is the Average Out-of-Pocket Cost for an Ambulance Ride? Without insurance, the base rate for an ambulance ride often starts between $400 and $1,200, with mileage fees ranging $10$30 per mile. Advanced Life Support (ALS) can cost anywhere from $975$1,300 (or more) for the trip alone.

What is the value code for ambulance billing?

HCPCS HCPCSDefinition A0434 Ambulance service, specialty care transport A0425 BLS/ALS mileage, per statue mile A0435 Fixed wing air mileage, per statute mile A0436 Rotary wing air mileage, per statute mile9 more rows Jan 22, 2024