GENERAL INFORMATION
First Name :
Last Name :
Title :
Name of Organization :
Address 1:
Address 2:
City: State: Zip:
Email Address:
Telephone :
ORGANIZATIONAL DEMOGRAPHICS
Type of Organization (please check one) Fire Service Hospital Based Service Private Service Third Service Volunteer Service Other
Annual Transport Call Volume (please check one) Less than 1,000 1,001 to 5,000 5,001 to 10,000 10,001 to 20,000 20,000+
Mode of Transportation (please check one) Ground Ambulance Air Ambulance Both Type of Service (please check all that apply) Emergency Non-Emergency
OPERATIONAL PROFILE Service Types (please check all that apply) Wheelchair BLS ALS SCT Rotorwing Fixed Wing Patient Care Report (please check one) Electronic Paper Both
Name of EPCR Product :
BILLING PROFILE Third Party Billing (please check one) Yes No
Billing Service (please check one) Internal External
Name of Billing Service (Optional):
Current Experience (please check one) Very Good Good Fair Poor
INFORMATION REQUEST
Service Requested (please check one) Billing and Reimbursement Services Billing Consultation Operational Consultation Other Services
Other Services :
Contact Me By (please check one) E Mail Mail Telephone
