North Jefferson County Ambulance District

Signature Authorization Form

Please complete the Signature Authorization Form below by filling out all sections which apply to you. Don't forget to sign the form. WE CANNOT PROCSS YOUR CLAIM UNTIL WE RECEIVE THIS COMPLETED SIGNATURE FORM. Thank you!

Patient ID or Run #
Patient Name
Patient Email Address
Today's Date
Type of Insurance
Name of Private Insurance Carrier
Insurance Policy ID #
Insurance Group #
Authorization	I request that payment of authorized Medicare, Medicaid, and/or other Insurance benefits be made either to me or on my behalf to North Jefferson County Ambulance District (NJCAD) for any service furnished to be by that supplier. I authorize any holder of hospital or medical information about me to be released to the Health Care Financing Administration and its agents and carriers as well as to North Jefferson County Ambulance District (NJCAD) any information or documentation needed to determine these benefits or the benefits payable for related services. I permit a copy of this authorization to be used in place of the original. I understand that this authorization may be used by the supplier for all services now and in the future until such time that I revoke this authorization in writing.

	By submitting this form, I agree to the above statement. Submit Form

Thank you for submitting the Signature Authorization Form.

If you have any questions, please feel free to contact us at billing@njcad.com.

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North Jefferson County EMS

3131 Rock Creek Road
High Ridge, MO 63049

(636) 677-3399

Signature Authorization Form

North Jefferson County EMS

3131 Rock Creek RoadHigh Ridge, MO 63049(636) 677-3399

Signature Authorization Form

3131 Rock Creek Road
High Ridge, MO 63049

(636) 677-3399