Empress/Emergacare Insurance Information

Invoice Information
Invoice Number*
You must provide the invoice number as listed on your bill. It should be in the general format of XX-XXXXX.
Account Number*
Please provide the account number as listed on your invoice.
Date of Service*

MonthDayYear
Important Information
Email Address*

Confirmation Email
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Social Security Number*
Please enter in form of XXX-XX-XXXX
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Insurance Information
Insurance Provider Name*
ID or Claim Number*
Policy Number*
Insurance Phone*

Area CodePhone Number
Insurance Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Adjuster's Name

First NameLast Name
Adjuster's Phone

Area CodePhone Number
Additional Insurance Information
Insurance Provider Name (Add.)
ID or Claim Number (Add.)
Policy Number (Add.)
Insurance Phone (Add.)

Area CodePhone Number
Insurance Address (Add.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Adjuster's Name (Add.)

First NameLast Name
Adjuster's Phone (Add.)

Area CodePhone Number
Additional Information
Additional Comments
For security purposes, please enter the text in the box below as seen here:*
Should be Empty: