General Organizational Information & Demographics

Legal Business Name

DBA

Address (Line 1)

Address (Line 2)

City

State

Zip Code

Business Phone Number

Fax Number

Employer ID Number

NPI #

Are you Currently Billing Under Medicare Part A?

Yes
No
Not Sure

Are you Currently Billing Under Medicare Part B?

Yes
No
Not Sure

Billing Address Information

Is billing name and address same as above? If NO, please complete all questions in this section.

Yes
No

Billing Name

(If different from Organization Name)

Address (Line 1)

Address (Line 2)

City

State

Zip Code

Business Phone Number

Fax Number

Payment Information

Address where payments should be sent.

Name

Address (Line 1)

Address (Line 2)

City

State

Zip Code

Department Attention

Are payments and paperwork electronically scanned?

Yes
No

Primary Contact Information

Name

First

Last

Department

Title

Business Phone Number

Mobile Phone Number

Fax Number

Email Address

Insurance Provider Information

Provider Name

Provider Number

Do you currently submit claims electronically to this provider? If YES, please provide info below.

Yes
No

ADD ANOTHER PROVIDER?

Yes

Secondary Insurance Provider Information

Provider Name

Provider Number

Contracted?

Yes
No

ADD ANOTHER PROVIDER?

Yes

Charges, Rates and Services

Please complete all that apply to your organization.

BLS Emergency Rate

BLS Non-Emergency Rate

BLS Mileage Rate

ALS Base Rate

ALS2 Base Rate

ALS Non-Emergency Base Rate

ALS Mileage Rate

Wheelchair Van Rate

Fixed Wing Base Rate

Fixed Wing Mileage Rate

Rotor Wing Base Rate

Rotor Wing Mileage Rate

Additional Charge Structure

Please complete all that apply to your organization.

Oxygen Charge

EKG Charge

Treat/No Transport Charge

Other Charge Description

Rate?

Health Care Procedure Code (HCPCS)

Please list other charges, their rates and HCPCS Codes your organization currently utilizes here or upload a separate document by using the UPLOAD button at the bottom of this section.

Will QMC do any back billing?

Yes
No

Services Offered

Facilities Serviced

Please provide a list of all facilities your organization currently services. Indicate facility type (e.g., acute care hospital, skilled nursing, etc.) address and main phone number. Provide to us in XLS (Excel) or CSV format and UPLOAD using the button below.

Drag & Drop Files, Choose Files to Upload

Facility Contracts

Is your organization currently contracted with any facilities?

Yes
No

Vehicles

Would you like QMC to track the individual activity of your vehicles?

Yes
No

Crew Activity

Please UPLOAD your crew information.

Drag & Drop Files, Choose Files to Upload

Reports

Who receives the month-end reports?

First

Last

Department

Title

Phone Number

Fax Number

Email Address

Receiving Trip Information

Will you be sending any original documentation to QMC?

Yes
No

Do you utilize an ePCR Program?

Yes
No

Are you able to provide copies of local protocols and a list of any specific definitions or codes for your county/region?

Yes
No

Are you able to provide a copy of your current PCS form?

Yes
No

Are you able to provide a copy of your current signature form?

Yes
No

Deposit Information

Does your organization currently have access to an electronic deposit information, e.g., lock box or FTP?

Yes
No

Accounts receivable contact person

First

Last

Title

Phone Number

Fax Number

Email Address

Collections/Bad Debt

Does your organization have a collections policy?

Yes
No

Subscribers & Subscriptions

Does your organization currently have a subscription program?

Yes
No

Time Pay Arrangements

Does your organization offer any time pay arrangements to your patients?

Yes
No

Notice of Privacy Practices (NPP)

Do you acknowledge/retain Notice of Privacy Practices (NPP) per the Health Insurance Portability and Accountability Act?

Yes
No

Does your organization retain Assignment of Benefits (AOB) Forms per CMS guidelines?

Yes
No

Please indicate whose signature should appear on the CMS-1500 Form for your organization?

First

Last

Title

Charity Policy

Does your organization currently have a charity care policy?

Yes
No

Patient Invoicing

Do you have a specific statement or specific wording that should be included on your patient invoices?

Yes
No

Do you have the ability to process a patient's credit card in-house?

Yes
No

Explain your typical dunning process, (e.g.: 0-day, 30-day, 60-day, 90-day)

Additional Information

Does your organization have additional programs or databases that contain patient information?

Yes
No

Does your organization have an interest in having direct access to patient accounts and reporting?

Yes
No

Has your organization been audited by any payor in the last 18-24 months?

Yes
No

Who are your organization's authorized and delegated officials with Medicare?

First

Last

Delegated Official #2

First

Last

Delegated Official #3

First

Last

Can you provide a letter from the Internal Revenue Service (IRS) indicating your legal business name?

Yes
No

Please upload a copy of your state EMS license.

Drag & Drop Files, Choose Files to Upload

Can you provide a copy of your CMS letter regarding completion of revalidation?

Yes
No

Comments

Please add your comment below. Questions? Need additional information? Call us at (800) 901-1155.

Origins and Destinations