E-Gov Services City of Selma

Ambulance Billing Inquiry

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Purpose. This form is used to communicate with city personnel to request services and request information.

* Information is required.

Contact Information

First Name:
Last Name:
Email:
Daytime Phone:	() –
Fax:	() –
Address:
City:
State:
ZIP:

* Patient's Name

* Patient's Address

* Date of Service

Nature of your Inquiry

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.