Patient Notebook

Ambulance Billing

www.arsnetwork.com/insauth.htm

5925 West Tilghman Street

Suite 1000

Allentown, PA 18104

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Error Summary

Please, correctly fill out all required fields.

1. Patient Information

First Name *

M.I.

Last Name *

Patient Account Number *

Date of Service Provided *

Name of Ambulance Service *

Email Address

2. Payment Amount

Amount

3. Payment Method

Credit/Debit Card

Bank Account

Name on Card *

Card Number *

Expiration Date *

Security Code *

Zip Code *

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