Health Insurance Information - FPSC

Health Insurance Information Form

Patient Information

Ambulance Service *

Located on the top right corner of your statement

First Name *

Middle Name

Last Name *

Date of Birth *

Phone No *

Patient No *

Located towards the top right corner of your statement in red

Call No*

Located underneath Patient Number

Primary Insurance (as read on your insurance card)

Insurance Provider

Member ID #

Group No

Upload your Insurance Card (Front)

Upload your Insurance Card (Back)

Subscriber's First Name

Middle Name

Subscriber's Last Name

Insurance Claim Submission Address

Usually on the back of the insurance card

Secondary Insurance (as read on your insurance card)

Insurance Provider

Member ID #

Group No

Upload your Insurance Card (Front)

Upload your Insurance Card (Back)

Subscriber's First Name

Middle Name

Subscriber's Last Name

Insurance Claim Submission Address

Usually on the back of the insurance card

Auto Insurance (as read on your insurance card)

Insurance Provider

Incident Claim Number

Insurance Claim Submission Address

Usually on the back of the insurance card