Medical Transport Billing Authorization Form
Patient Information
Patient Name
Date of Birth
Address
Phone Number
Insurance Provider
Policy Number
Transport Details
Date of Transport
Pick-up Location
Destination
Reason for Transport
Mode of Transport
Ambulance
Wheelchair Van
Stretcher Van
Other
Authorization
Authorized By
Relationship to Patient
Date
Signature
By signing, you authorize the release of medical and insurance information as needed for payment processing.