Purpose. This form is used to communicate with Fire Department personnel to request information regarding your EMS billing for emergency ambulance transports.
* Information is required.
Contact Information
| What was the date of the emergency transport? |
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| Please list the patients name and date of birth. |
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| Nature of the complaint/suggestion... |
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Check here to have email confirmation of this request sent.
* Information is required.
Notes:
If you send us a message, you'll receive a Tracking Number allowing you to follow-up with your request, at your convenience.
Information we receive may be considered public information which is subject to disclosure under current state law. Learn more about our Privacy Policy.
Internal Use Only, Leave Blank:
Please leave this field blank and remove any values that have been populated for it.
