(Located on bill, under Patient Name)
CITY OF LONG BEACH
DEPARTMENT OF FINANCIAL MANAGEMENT
333 West Ocean Boulevard, Lobby Level • Long Beach, CA 90802 • Phone (562) 570-7600 • Fax (562) 570-6783
Emergency Ambulance Service - Request for Medical Insurance Information
Please note that charges for the recent emergency medical services provided by the Long
Beach Fire Department are now due for payment. Please provide medical insurance
information requested on this form so that we may bill your insurance provider for the
charges listed on your bill. If you do not provide the required medical insurance
information, you will be responsible to pay the billed charges by the due date.
Please fill out the form below and return to our office promptly. Please mail the form to
City of Long Beach, Attn: Ambulance Billing, P.O. Box 22600, Long Beach, CA 90801 or
email it to the City at AmbulanceBilling@LongBeach.gov. Also, please include a front and
back copy of your insurance card(s) if possible.
Primary Insurance
Type of Insurance:_____________________________________________________________
Insurance Company Name:______________________________________________________
Member Number/Claim Number/Policy Number:______________________________________
Address:_______________________________________ City:__________________________
State:____ Zip Code:_____________ Phone Number:_________________________________
Secondary Insurance
Type of Insurance:_____________________________________________________________
Insurance Company Name:______________________________________________________
Member Number/Claim Number/Policy Number:______________________________________
Address:_______________________________________ City:__________________________
State:____ Zip Code:_____________ Phone Number:_________________________________
Additional Insurance to Bill
Type of Insurance:_____________________________________________________________
Insurance Company Name:______________________________________________________
Member Number/Claim Number/Policy Number:______________________________________
Address:_______________________________________ City:__________________________
State:____ Zip Code:_____________ Phone Number:_________________________________
Authorization for release of Medical Information:
I authorize any holder of Medical information about me to release to Medicare, Medicaid and any
insurance, as well as the provider of this service, any information or documentation in their
possession needed to determine these benefits or the benefits payable for related service, whether
in the past, now, or in the future.
______________________________________ ____________________________________
Signature of Patient, Guarantor, Parent, or Guardian Print Name
_________________________
Date Run #________________________
