Rescue Bill Form

Fields marked with an asterisk * are required.

Rescue Information
Fire Company*
Incident Date*	Date format: mm/dd/yyyy
Incident Time*
Incident Number*
Incident Location
Incident Address*
Incident City*
Incident State*
Level of Rescue
Incident Type*	Vehicle Collision Vehicle Fire Spill/Hazmat Lock Out
Equipment Utilized
Equipment	Air tools Axe/halligen bar CO2 extinguisher Dry chem extinguisher Gas tank plug kit Glass master Hand lights Mounted power unit O-cutters Pedal cutter Portable power unit Rams small Rams large Saw-Zall Saw-Zall blades Secure battery Spreader Thermal image Toolbox Wrench 2x4 cribbing # minutes 4x4 cribbing # minutes Air bags # minutes Debris removal # minutes Extrication time # minutes Oil dry # bags Scene lighting # minutes Stabilization struts # minutes Step chock # used Traffic control # minutes
Patient Information
Patient Name*
Patient Phone*
Patient Address*
Patient City*
Patient State*
Vehicle Insurance Information
Insurance Company*
Policy Number*
Vehicle Vin #*
Officer in Charge*
Additional Information

Kirk & Associates LLC

56 W. Main St, Suite 203, Plaza 273Christiana, DE 19702 T: (302) 273-2247 T: (302) 273-2247 F: (302) 533-6818 F: (302) 533-6818

Services: medical billing, medical coding, physician billing, coding expertise, insurance verification, AR/denial management, collection agency, carrier contract negotiation, coding education, third party auditing, diagnostic coding, HIPAA compliant, ICD9 and ICD10 compatible.

Ruby Creek Design, An Albuquerque Web Design Company

Rescue Bill Form

Rescue Information

Incident Location

Level of Rescue

Equipment Utilized

Patient Information

Vehicle Insurance Information