Medicare and Billing-Related Forms

Our Medicare and Billing Forms have been used by organizations all throughout the USA.  Take a look for yourself!

Medicare and Billing Forms

Sample Ambulance Signature/Claim Submission Authorization Form (v2.2) 

Word PDF Instructions

Physician Certification Statement (v1.6)

Word PDF Instructions

Sample Signature Attestation Statements (v1.1)

  PDF  

Sample Signature Logs (v1.2)

  PDF  

Sample Advance Beneficiary Notice of Noncoverage*

Word PDF  
Model Ambulance Signature Claim Submission Form Version 2.2 Word PDF  

*Note: this is an official government form, only limited modification is permissible, and PWW makes no copyright claim over government works.

IMPORTANT:  By clicking any of these links and/or downloading any of these documents, you agree to the Terms of Use spelled out below.  DO NOT download any of these documents if you do not agree to these terms. If you download any documents, you agree to these Terms of Use.

Medicare and Billing-Related Forms: Any individual or entity who downloads or uses these documents or any modified version of any of these documents in any way is referred to as the "User." The documents made available for download on this site are sample forms and policies only, designed to assist ambulance services in complying with applicable requirements. These documents are not legal advice, and no attorney-client relationship is formed by their use. Unless otherwise noted, these documents are not official forms of any governmental agency and may not reflect requirements of state law where you live. User bears all responsibility for compliance with all applicable laws and regulations, and the User agrees that neither Page, Wolfberg & Wirth, LLC nor the individual designers of these documents are not responsible for their use, non-use or modification by any User. Do not use any of these documents or any modifications of them if you do not agree to the terms and conditions of this license. These documents may be modified by the User to meet the User's needs, though we bear no responsibility for any modifications. These documents are licensed only for use by individual ambulance services, and may not be sold or distributed by any other individual or entity. Any other use or distribution of these documents requires our express written permission.  Please also note that we expect to periodically update these documents for various reasons, and we cannot be responsible to distribute new or updated forms to users.  In addition, we do not guarantee that these documents will be updated to reflect new laws, regulations or other applicable authority.  All documents are Copyrighted by Page, Wolfberg & Wirth, LLC, and any use, reproduction or distribution that is not in accordance with these Terms of Use is strictly prohibited unless permitted in writing by Page, Wolfberg & Wirth, LLC.