BARS Billing Form

New Run

Run # Date of Service Time of Service

Patient Information

Last Name First Name DOB Address City State Zip Phone

Gender M F

Marital Status Married Single Div. Wid. N/A

Employment Employed Retired Student Unemployed

Billing Information

Medicare # Insurance Name Medicaid # Group # Policy # Insured Name (if different) Relation to Patient

Motor Vehicle Crash? Yes No

Work Related? Yes No

Call Information

Crew Chief

Cert Level EMT AEMT PARAMEDIC

Location of Call

Destination RRMC PMC Other

Destination (if Other) Dispatched As Chief Complaint(s)

BLS O2 Splints Immobilization Dressings Temp

ALS1 IV Monitor Finger Glucose Medication?

ALS2 CPAP IO ETCO2 Medication 1 Medication 2 Medication 3

Paramedic Intercept Mileage Hospital Physician

Billing Authorization & Privacy Acknowledgment

Is the patient physically and mentally able to sign?

Is an authorized representative (legal guardian or healthcare POA) available and willing to sign?

Section I — Patient Signature

Patient is a minor (parent/guardian signs) Patient signed with an "X" / mark, not a full signature

Patient Signature

Signature accepted — locked.

Witness Signature (required — patient signed with a mark)

Signature accepted — locked.

Section II — Authorized Representative Signature

Explain why it's impractical for the patient to sign Printed Name of Representative

Representative is the patient's Legal Guardian Healthcare Power of Attorney

Representative Signature

Signature accepted — locked.

Section III — Ambulance Crew & Receiving Facility Signatures

A. Ambulance Crew Member Statement

Explain the circumstances that make it impractical for the patient to sign Name and Location of Receiving Facility Facility Location Time at Receiving Facility Printed Name and Title of Crewmember

Signature of Crewmember

Signature accepted — locked.

Receiving Facility Representative Signature

Hand the iPad to the receiving facility representative to sign below.

Printed Name and Title of Receiving Facility Representative

Signature of Receiving Facility Representative

Signature accepted — locked.

This form has been submitted and is now read-only.

BARS Billing

Runs

New Run

Patient Information

Billing Information

Call Information

Billing Authorization & Privacy Acknowledgment

Section I — Patient Signature

Section II — Authorized Representative Signature

Section III — Ambulance Crew & Receiving Facility Signatures

A. Ambulance Crew Member Statement

Receiving Facility Representative Signature