Exhibit_A.2_-_VC_EMS_Invoice_Template_updated_5-2024.pdf
PDF 1 MB Posted
- Attached to
- EMS Invoicing Services
- Solicitation number
- 26-B-68TF
- Issued by
- Volusia County, Florida
About this file
This is an invoice template document for the County of Volusia Emergency Medical Services (EMS) Division in Holly Hill, Florida, which serves as the standardized billing form for ambulance and medical services provided countywide. The template is designed to capture patient demographic information, insurance details for both primary and secondary coverage, and payment processing options including checks and major credit cards (MasterCard, Visa, American Express, and Discover). The form accommodates Medicare Part B claims and Medicaid patients, as well as claims from other insurance carriers, with correspondence directed to the EMS main office at 112 Carswell Ave, Holly Hill, FL 32117-5010. The invoice template includes lifetime assignment of claim authorization language and requires patients to provide and update insurance information as needed.
The document reflects the County's compliance requirements under the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act, as EMS invoicing services must adhere to these federal regulations. The template provides contact information for the Daytona Area office at (386) 252-4900 and a toll-free number at 1-800-323-3822 for patients and insurance inquiries. This standardized invoice form is part of the County's broader EMS invoicing services initiative, which was subject to competitive sealed proposals to identify qualified contractors capable of managing the billing and revenue cycle for the Division's billable services to Medicare, Medicaid, and other insurance providers.
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Text version
ADDRESSEE: MAKE CHECKS PAYABLE TO:
PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT
County of Volusia Emergency Medical Services 112 Carswell Ave.
Holly Hill, FL 32117-5010
DATE PAY THIS AMOUNT INVOICE NUMBER
AMOUNT PAID
IF PAYING BY MASTERCARD, VISA, DISCOVER OR AMERICAN EXPRESS, FILL OUT BELOW.
CHECK CARD USING FOR PAYMENT
CARD NUMBER SEC. CODE
SIGNATURE EXP. DATE
MASTERCARD VISA AMERICAN EXPRESSDISCOVER
PATIENT NAME
MEDICARE PATIENTS
covered and medically necessary Medicare Part B claims.
MEDICAID PATIENTS
OTHER INSURANCES
SEND CORRESPONDENCE TO:
County of Volusia Emergency Medical Services 112 Carswell Ave.
Holly Hill, FL 32117-5010
Signature te
YOUR NAME (Last, First, Middle Initial)
ADDRESS
CITY STATE ZIP
TELEPHONE MARITAL STATUS o Separated o Single o Divorced
( ) o Married o Widowed
D.O.B. SOCIAL SECURITY NUMBER
YOUR PRIMARY INSURANCE COMPANY’S NAME EFFECTIVE DATE
PRIMARY INSURANCE CO. CLAIMS MAILING ADDRESS PH. FOR CLAIMS
CITY STATE ZIP
POLICYHOLDER’S ID NUMBER GROUP PLAN NUMBER
SECONDARY INSURANCE COMPANY’S NAME EFFECTIVE DATE
SECONDARY INSURANCE CO. CLAIMS MAILING ADDRESS PH. FOR CLAIMS
CITY STATE ZIP
POLICYHOLDER’S ID NUMBER GROUP PLAN NUMBER
ABOUT YOU: ABOUT YOUR INSURANCE:
IMPORTANT PHONE NUMBERS
Daytona Area (386) 252-4900 Toll-Free 1-800-323-3822
LIFETIME ASSIGNMENT OF CLAIM AND AUTHORIZATION – PROVIDE INSURANCE INFORMATION
or in the future.
PLEASE UPDATE ANY INFORMATION THAT HAS CHANGED SINCE YOUR LAST STATEMENT
File details come from the government source that posted it. Updated .