Ambulance Transport Billing Services

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For more information about how your agency can financially benefit from billing for EMS/ambulance services, or how switching to Diversified Ambulance Billing can improve your bottom line, please provide us with the following information:

Name
Title
Name of Dept., Agency or Service
Address
E-mail
Telephone Number
Contact me by:	Mail E-mail Telephone
Type of Organization:
Primary Service Area:
Primary Service Area Population:
Number of annual EMS or Ambulance responses in primary service area:
Number of annual Ambulance transports in primary service area:
What type of patient care reporting does your agency use?	Paper Forms Only Electronic Forms Only Paper & ElectronicForms Uncertain
Does your agency currently charge for EMS/Ambulance services?	Yes No Uncertain
Does your agency currently have a medicare provider number?	Yes No Uncertain
Does your agency already use an outside billing service?	Yes No Uncertain
How did you hear about DAB?

	Information and Client Services please call: Toll Free (800) 355-1753 info@dabill.com Mid-Atlantic Region 397 Little Neck Road, Bldg 3300 South, Suite 300 Virginia Beach, VA 23452 Ph:(757) 557-0833 \| Fax: (757) 557-0943 \| Toll Free (800) 355-17533 Southeast Region 10002 Princess Palm Avenue, Suite 124 Tampa, Florida 33619 Office (813) 635-9202 \| Fax: (813) 635-0605 \| Toll Free (800) 355-1753 top

	MID-ATLANTIC REGION 397 Little Neck Road, Bldg 3300 South, Suite 300 Virginia Beach, VA 23452 Ph:(757) 557-0833 Fx: (757) 557-0943 Toll Free (800) 355-1753
	SOUTHEAST REGION 10002 Princess Palm Ave., Suite 124 Tampa, Florida 33619 Ph:(813) 635-9202 Fx: (813) 635-0605 Toll Free (800) 355-1753
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