close icon

Download forms

Medicare Redetermination Request Form
(to be completed by Medicare recipient if claim is denied by Medicare)

Hospitals/Air Ambulance/Nursing Home Facilities:

Physician’s Certification Statement for Ambulance Transportation [PDF]
(to be completed by physician requesting patient transfer between facilities)

Guarantee of Payment [PDF]
(to be completed by physician/hospital initiating non-emergency patient transfer between facilities)

Credit Card Authorization Form [PDF]
(to be completed by EVAC personnel and faxed to facility that guarantees payment for transfer)


    How Can We Serve You?

    Contact Us

    If you don't find what you're looking for you can reach out to us through our contact form. Thank you!

    123 W. Indiana Ave.
    DeLand, FL 32720
    (386) 736-2700

    We use cookies to provide and improve our services. By using our site, you consent to cookies.