HomeMy WebLinkAboutRequest-for-Information-form Palm Desert COVE COMMUNITIES
PO BOX 269110
SACRAMENTO CA 95826-9110
1(800) 906-6552 PST - 8:00am to 4:30pm
SEITINUMMOC EVOC
011962 XOB OP
0119-62859 AC OTNEMARCAS
RE: Run Number: 18-123456 Incident No: 18000111
REQUEST FOR INFORMATION – ONLY-(This is not a Bill) Recently emergency medical services were provided to you by the Riverside County Fire Department. As a resident of the Cove
Communi�es (Rancho Mirage, Indian Wells, and Palm Desert), you are protected from out-of-pocket costs related to
emergency paramedic and ambulance transporta�on services. We know that private insurance; Medi-Cal and Medicare
frequently leave various parts of the bill unpaid, ci�ng limita�ons in the policy. It is important for you to understand that as a
resident you will not be held financially responsible for any balances a�er insurance.
However, per resolu�on No. 2017-31, passed in February of 2017, the Cove Community Ci�es will bill Medicare, Medi-Cal,
Medicaid and Private Companies of Residents to recover costs incurred from the medical emergency. These funds support the
Cove Community Ci�es emergency responses to cri�cal life and health situa�ons in the community. In order to properly bill for the paramedic transport services rendered to you, we ask that you contact us as soon as possible so
that we may confirm applicable billing informa�on. We can be reached at 1-800-906-6552 (Pacific Time). You may also submit
your insurance informa�on at h�ps://www.webillems.com/secure or fill out and return the form below. Thank you for your �me,
The Cove Community Cities
HEALTH INSURANCE:
Insurance Name:
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ID# or Member#: Pa�ent DOB: ________________________________________________
AUTO INSURANCE (IF APPLICABLE):
Auto Insurance Name:
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:piZ :etatS:ytiC :sserddA
Phone #:
Workers Compensation (IF APPLICABLE):
Insurance Name:
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Authorization for release of Medical Information:
I authorize any holder of Medical informa�on about me to release to Medicare, Medicaid and any insurance, as well as the
provider of this service, any informa�on or documenta�on in their possession needed to determine these benefits or the
benefits payable for related services, whether in the past, now or in the future.
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FOR INQUIRIES CALL TOLL FREE 1(800) 906-6552 PST - 8:00am to 4:30pm.
You may also submit insurance informa�on at www.webillems.com/secure
A18-274227B
7000000415 00.0003.0014 415/1WMN0711A
JANE DOE123 ANY STREETPALM DESERT CA 12345-1234