PAB Bill Pay
Insurance Submission
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Insurance Submission
Your Medical Billing Professionals
(716) 204-3350 or (888) 897-4893
Patient and Call Information:
Call Number on Bill:
Date of Call/Service:
Ambulance Service Used:
Patient Full Name:
Patient Address:
Address Line 2:
City:
State:
New York
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Zip Code:
Email Address:*
Phone Number:*
Patient Insurance Information:
Name of Primary Insurance Company:
Name of Insured:
Policy Number:
Name of Secondary Insurance Company:
Name of Insured:
Policy Number