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Covid-19 Resources Client Portal Patient Portal Education Portal
  • EMS AGENCY DATA

  • EMS|MC will use this name for all reporting, invoicing, and applications.
  • Drop files here or
    Max. file size: 50 MB.
    • Station:Address:Telephone #:Date Established: 
      A practicing location is defined as anything leased, owned, or provided by an entity to operate out of.
    • If month and date are unknown, please provide the year.
    • Max. file size: 50 MB.
    • Drop files here or
      Max. file size: 50 MB.
      • Max. file size: 50 MB.
      • Max. file size: 50 MB.
      • MM slash DD slash YYYY
      • Max. file size: 50 MB.
        Not applicable for government agencies
      • Name:Ownership Percentage: 
      • MM slash DD slash YYYY
      • Name:Telephone #:Email Address: 
      • MM slash DD slash YYYY
      • Please enter a number greater than or equal to 0.
        This estimation should be based on DOS rather than billing period.
      • Please enter a number greater than or equal to 0.
        This estimation should be based on DOS rather than billing period.
      • EMS AGENCY CONTACTS

      • Primary Contact

      • Work Phone:Cell Phone:Fax Number:Email: 
      • Primary Billing/Documentation Contact

      • Work Phone:Cell Phone:Fax Number:Email: 
      • Primary Financial Contact
      • Work Phone:Cell Phone:Fax Number:Email: 
      • NameTitleAddressTelephoneCellEmail 
      • Please refer to last submitted 855B application; we will be asking for a copy of this further into the deployment process.
        PECOS is the online Medicare enrollment management system.
      • DEPOSIT PROCESS

        E.g. Health Department
        These banks include but are not limited to: • Bank of America • Bank of the Ozarks • BB&T • Capital Bank (new) • Fidelity • First Bank • First Citizens • PNC • Suntrust • Wells Fargo • Pinnacle Financial Partners
      • NameTelephone NumberEmail 
      • PAYER INFORMATION

      • E.g. Health Department
      • Payer:ID Number:Effective Dates: 
        Medicare, Medicaid, Railroad Medicare, BlueCross BlueShield, Aetna, Humana, Tricare, Department of Labor, and United Health Care
      • Drop files here or
        Max. file size: 50 MB.
        • MedicareMedicaid
        • Name:Effective Date: 
        • Drop files here or
          Max. file size: 50 MB.
          • Examples include: Medicare, Medicaid, BCBS/Anthem, Aetna, UHC. If none, please list "none".
          • Examples include: Medicare, Medicaid, BCBS/Anthem, Aetna, UHC. If none, please list "none".
          • Examples include: Medicare, Medicaid, BCBS/Anthem, Aetna, UHC. If none, please list "none".
          • ePCR Information

          • E.g. "Ready to be billed", or "QM approved"
          • Is there a dedicated role assigned to Q/A trips?
          • Agency Name:Address:City:State:Zip Code:Contact Name:Contact Phone Number:Email: 
            Punctuation, spacing, and upper/lower case are important.
          • Name of Correctional Facility:Privately Owned or Government Funded:Address:City:State:Zip Code: 
          • CUSTOMER SERVICE POLICIES

          • NameTitlePhone NumberEmail 
          • Max. file size: 50 MB.
          • NameTitleTelephone NumberEmail 
          • Please enter a number greater than or equal to 0.
          • LEGAL AND ESTATES

          • BILLING PROCEDURES

          • E.g. zip code, county residence, etc.
          • Drop files here or
            Max. file size: 50 MB.
            • Drop files here or
              Max. file size: 50 MB.
              • e.g. Alpha, Bravo, Charlie, etc.
              • Drop files here or
                Max. file size: 50 MB.
                  E.g. Prison, County/City Jail, Hospice, Nursing Facility, Hospital, etc.
                • NameAddressContracted Rate 
                  If none, note "none" or "n/a"
                • Drop files here or
                  Max. file size: 50 MB.
                  • E.g. Prison, County/City Jail, Hospice, Nursing Facility, Hospital, etc.
                  • NameAddress 
                  • EMS|MC will add a mileage cap to our billing system to flag unusually high mileage.
                  • Drop files here or
                    Max. file size: 50 MB.
                    • E.g. members of public safety, city employees, county employees?
                    • MS|MC requires medical necessity forms such as a Physician Certification Statement (PCS) or EMTALA form to bill scheduled transports
                    • Patient deceased prior to dispatch:Patient pronounced deceased at the scene:Patient pronounced deceased enroute or at hospital: 
                    • Be specific: Bill as BLS-E? Cancel the trip? Charge a different rate based on services rendered (i.e. whether it is only a lift assist response, MVA response, or certain supplies are used)?
                    • Be specific: List locations, special rates or any other special billing policies.
                    • 88. Please provide your current rates for the following (please enter 0 if not applicable):
                    • Max. file size: 50 MB.
                    • Max. file size: 50 MB.
                      Air Carrier/Air Operator Certificate
                    • Max. file size: 50 MB.
                    • Max. file size: 50 MB.
                    • BILLING PROCESS CONTINUED
                    • Name 
                    • Max. file size: 50 MB.
                    • Name of CountryIT Department Contact NameIT Department Phone NumberIT Department E-mail Address 
                    • 97. Do your crew members collect this information? Please select "Yes" or "No" for each:
                    • E.g. wheelchair transports, etc.
                    • FACILITY AND HOSPITAL INFORMATION

                    • 99. Please supply a list of the following facilities, if applicable:
                    • Hospital NameEstimated Annual VolumeEstimated Annual %Hospital AddressContact NameContact NumberContact Email 
                    • Facility NameFacility AddressContact NameContact NumberContact Email 
                    • Please list the facility and its out of county mileage
                    • COLLECTIONS, DEBT SETOFF (State Tax Garnishment), AND WAGE GARNISHMENT INFORMATION

                    • Agency Name:Agency Address:Contact Name:Contact Number:Contact Email: 
                    • NameTitlePhone NumberEmail 
                    • NameTitlePhone NumberEmail 
                    • Drop files here or
                      Max. file size: 50 MB.
                      • NameTitlePhone NumberEmail 
                      • NameTitlePhone NumberEmail 
                      • Hold down the Ctrl key to select multiple choices.
                      • COLLECTIONS, DEBT SETOFF (State Tax Garnishment), AND WAGE GARNISHMENT INFORMATION
                      • If no, we will collect insurance payments and take no further action. The rest will be written off.
                      • EMS|MC REPORTING INFORMATION

                      • NameEmail 
                        ACR Return to Provider = This report provides feedback on patient call reports and highlights missing information so that better documentation practices can be utilized.
                      • NameEmail 
                        ACR Return to Provider = This report provides feedback on patient call reports and highlights missing information so that better documentation practices can be utilized.
                      • NameEmail 
                        Constant Contact = This is the main line for your EMS agency to receive global alerts and notifications from EMS|MC.
                      • NameEmail 
                        Import Confirmation Report = This report shows the number of trips imported into our system.
                      • NameEmail 
                        Missing Signature Report = This report identifies trips that are missing signatures so that inaccurate documentation habits can be corrected.
                      • NameEmail 
                        Month End Report = This report is a financial review of your EMS agency's account at EMS|MC.
                      • NameEmail 
                        Payments Summary Report = This report is a deposit workbooks that tracks payments made between EMS|MC and your EMS agency.
                      • NameEmail 
                        Refunds Report = This report summarizes the refunds that have been issued to payers, patients, or other recipients.
                      • FORM SUBMISSION

                      • Please list only one email address.
                      • 12345678910
                        1-lowest satisfaction, 10-highest satisfaction
                      • END OF FORM

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                      EMSpire Logo

                      Every year, we look forward to connecting our clients to industry experts from across the nation, but given the effect of COVID-19 on the EMS industry, we’ve made the decision to cancel EMSpire 2020.

                      Join us in April 2021 for EMSpire where we will come together to celebrate first responders and our 25th anniversary!

                      Wednesday & Thursday, April 21-22, 2021

                      Grandover Resort & Conference Center

                      One Thousand Club Road, Greensboro, NC 27407

                      This day and a half event celebrates learning & networking opportunity among peers & industry experts.

                      Detailed information regarding the agenda & early bird registration is coming your way.

                      Make plans to attend today!

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                      Patient Customer Service:
                      800.814.5339

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                      Main Corporate Number:
                      336.397.3975

                      Mailing Address:
                      PO Box 863, Lewisville, NC 27023

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