APA EMS INSURANCE SUBMISSION

CORPORATE HEADQUARTERS
16945 Sherman Way
Van Nuys, CA 91406
(818) 996-2200

Insurance Submission

* Required fields

Patient Information

*Patient First / Last Name:
*Ticket Number:
*Date of Services:	mm/dd/yyyy
*Patient's DOB:	mm/dd/yyyy
Patient's Address:
Patient's City
Patient's State
Patient's Zip
*Patient's Phone:	(including area code) (xxx-xxx-xxxx)

Insurance Information

Insurance Provider:
Insured's Name:
Date Issue:	mm/dd/yyyy
Insured Employer:
Insured I.D. Number:
Insured Group:
Employer Phone:	(including area code) (xxx-xxx-xxxx)

Credit Card Information

Billing Information

If Billing address is the same as above click here
Billing Address:
Billing Phone:	(including area code) (xxx-xxx-xxxx)
Billing City
Billing State
Zip