North Jefferson County Ambulance District

Signature Authorization Form

Please complete the Authorization Form below by filling out any sections which apply to you. Don't forget to sign the form. Please return this form to us as soon as possible. WE CANNOT PROCSS YOUR CLAIM UNTIL WE RECEIVE THIS SIGNATURE FORM. Thank you!

Patient ID or Run #
Patient Name
Patient Address
Patient Email Address
Date
Name as it appears on insurance card
Relationship to Patient
Patient Medicare #
Patient Medicaid #
Other Insurance Company Name
Insurance Address
Insurance Phone #
Insurance Policy ID #
Insurance Group #
Insured Name
Insured Date of Birth
Yes I do Authorize	I request that payment of authorized Medicare, Medicaid, and/or other Insurance benefits be made either to me or on my behalf to North Jefferson County Ambulance District (NJCAD) for any service furnished to be by that supplier. I authorize any holder of hospital or medical information about me to be released to the Health Care Financing Administration and its agents and carriers as well as to North Jefferson County Ambulance District (NJCAD) any information or documentation needed to determin these benefits or the benefits payable for related services. I permit a copy of this authorization to be used in place of the original. I understand that this authorization may be used by the supplierfor all services no and in the future until such time that I revoke this authorization in writing.

	By submitting this form, I agree to the above statement. Submit Form

Thank you for submitting the Signature Authorization Form.

If you have any questions, please feel free to contact us at [email protected]

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North Jefferson County Ambulance District

3131 Rock Creek RoadHigh Ridge, MO 63049(636) 677-3399

Signature Authorization Form

3131 Rock Creek Road
High Ridge, MO 63049

(636) 677-3399