Insurance Submission

Convenience and security are at the forefront of CAG’s insurance information submission process. Please use the online form below to submit your insurance details to our secure billing department. Rest assured that this form will not be kept on this site once it is finished. Your information is protected as we immediately transfer it to an encrypted file to maintain confidentiality.

Should you have any questions or concerns, our dedicated team is here to assist you. Feel free to reach out to us at (800) 336-6402 Monday through Thursday from 8:30 a.m. to 5:00 p.m. and Friday from 8:30 a.m. to 3:00 p.m. We are committed to providing excellent customer service and ensuring that your experience with us is seamless and hassle-free.

Name *

First

Last

Phone Number *

Email *

Patient Name (If Different from above)

Patient Address *

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Form

Fill out your information manually or you can just provide your Name, Phone number, Email, Patient Address and upload your Insurance Card below and submit the form.

Checkboxes

Manually add the information

Special Instructions/Comments:

Electronic Signature *

Signature

By clicking this form, I attest that I am the Patient or the Responsible Party of the Patient. I request that payment of authorized Medicare, Medicaid and /or other Insurance benefits be made either tome or on my behalf to ambulance service providing care for any services furnished to me by that supplier. I authorize any holder of hospital or medical information about me to release to the Centers for Medicare and Medicaid Services and its agents and carriers as well as to ambulance service providing care any information of documentation needed to determine 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 supplier for all services as it relates to this emergency call.

File Upload

Click or drag a file to this area to upload.