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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.
    • MM slash DD slash YYYY
    • Max. file size: 50 MB.
    • MM slash DD slash YYYY
    • MM slash DD slash YYYY
    • MM slash DD slash YYYY
    • Please enter a number greater than or equal to 0.
    • Please enter a number greater than or equal to 0.
    • Primary Agency Contact
    • EMS AGENCY CONTACTS

    • Primary Billing/Documentation Contact

    • Primary Financial Contact
    • Please list name title, address, phone/cell/fax, and email.
    • DEPOSIT PROCESS

    • PAYER INFORMATION

    • Drop files here or
      Max. file size: 50 MB.
      • Drop files here or
        Max. file size: 50 MB.
        • Hold down the Ctrl key to select multiple choices.
        • Hold down the Ctrl key to select multiple choices.
        • Hold down the Ctrl key to select multiple choices.
        • ePCR Information

        • We need the Agency Name, Address, City, State, Zip Code, Contact Name, Contact Phone number and email.
        • CUSTOMER SERVICE POLICIES

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

        • BILLING PROCEDURES

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          Max. file size: 50 MB.
          • Drop files here or
            Max. file size: 50 MB.
            • EMS|MC will add a mileage cap to our billing system to flag unusually high mileage.
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              Max. file size: 50 MB.
              • COLLECTION PROCESS CONTINUED
              • Please provide your current rates for the following (please enter 0 if not applicable):
              • Max. file size: 50 MB.
              • Max. file size: 50 MB.
              • Max. file size: 50 MB.
              • Max. file size: 50 MB.
              • Max. file size: 50 MB.
              • COLLECTION PROCESS CONTINUED
              • Max. file size: 50 MB.
              • Do your crew members collect this information? Please select Yes or No for each.
              • FACILITY AND HOSPITAL INFORMATION

              • Please supply a list of the following facilities, if applicable:
              • Please list the Hospital Name, Estimated Annual Volume Number, Estimated Annual Volume Percentage, Address, and a point of contact for us (name, number, email).
              • Please provide the Name and Address as well as a point of contact for each facility (name, number, email).
              • Please list the facility and its out of county mileage
              • COLLECTIONS, DEBT SETOFF (State Tax Garnishment), AND WAGE GARNISHMENT INFORMATION

              • 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

              • ACR Return to Provider Report (PCR documentation clarification report available 24/7 via EMSight Client Portal Website)ACR Return to Provider Report (Daily (or as completed) notification of trips placed on report via email)Constant Contact Email (Global alerts and notifications from EMS|MC via email)EMS|MC Invoice (Monthly via email)Import Confirmation (Trip import report sent as completed via FTP)Missing Signatures (Signature documentation feedback sent weekly via FTP)Month-End Report (Financial reports sent monthly via FTP)Payment Summary (Deposit workbook and payment information available 24/7 via EMSight Client Portal Website)Refunds (Refund information sent weekly or as completed via FTP) 
              • FORM SUBMISSION

              • Please list only one email address.
              • 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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