Quad Billing - Professional Ambulance Billing Services

Patient Billing Insurance Info
IF NO INSURANCE COVERAGE, OR A BALANCE IS DUE AFTER INSURANCE PAID, PLEASE REMIT PAYMENT TO ADDRESS PROVIDED ON YOUR BILL.

Name
Address
City, State, Zip	, ,
Account #
Date of Service
Please provide your insurance information below
Medicare Claim #
Medicaid Recipient Id #
Blue Cross/Blue Shield Group #
Contract #
Commercial Insurance Information
Insurance Name
Address
Group #
Policy/Contract
If Auto Accident, Provide Health And Auto Insurance
Auto Insurance Name
Claim #
Address
Contact Phone #
Questions Or Comments

Quad Billing, LLC
Phone: 303-680-9860
Fax: 303-617-0135