Form Download Page

All of our forms are in Adobe Acrobat form (.pdf). You will need the Adobe Acrobat Reader or Adobe Acrobat to view them. If you do not have Adobe Acrobat Reader, you can download the latest version free at: http://www.adobe.com/products/acrobat/readstep2.html

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Privacy Statement This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Insurance Claim Information Form Download this form if you need to send us your insurance information.

Medicare Secondary Insurance Form If you have Medicare and a Secondary Insurance, you can use this form to provide us with your secondary insurance information. Please note that many secondary insurance companies also require a copy to the Explanation of Benefits (EOB) or Medicare Summary Notice, to be able to process your claim. If you have this please provide it along with the Medicare Secondary Insurance Form.

Ambulance Transport Questionnaire If you have used our services and would like to comment on them, download this form and return it to our business office. We use this information to see how we can serve you better.

Application for Employment If you are a IL Licensed EMT and would be interested in work with us, please complete the Application and return it to our office. In addition to being an IL licensed EMT you must also have a valid AHA or Red Cross HealthCare provider CPR Card. If you are Paramedic you must also have a valid BTLS and ACLS card. The Staunton Area Ambulance Service is an Equal Opportunity Employer.