As one of our patients, you deserve honest answers to any questions you may have and access to all your rights and responsibilities. Find everything you need to know about our privacy practices/policies, billing policies, and other patient forms below.
If you have questions, don’t hesitate to contact our office at (518) 828-5175 for Operations or (518) 822-8511 for Billing. You can also visit our frequently asked questions page for additional information.
Downloadable Forms
- Ambulance Signature Claim Form (pdf) – According to insurance and Medicare guidelines we are required to have a signature on file prior to billing insurance or Medicare for ambulance services. If you were unable to sign your name or family representative was unavailable at the time of service, please download and complete this form.
- Record Release Form (pdf) – Patients, legal guardians, or representatives of patients wishing to request records from Greenport Rescue Squad must complete an Authorization to Release Information form. In order for us to process your request, all contact information for the person receiving the records must be completed, along with required documentation for identification when this form is submitted.
- NYS No Fault Insurance Form (pdf) – If you are involved in a motor vehicle accident, we want to be sure that proper billing is handled seamlessly. To ensure that Greenport Rescue Squad is authorized to bill your insurance company directly for services rendered, please complete and send three copies of the Assignment Form attached as well as NYS (AOB) Assignment of Benefits.
- Privacy Practices (pdf) – Greenport Rescue Squad is committed to protecting your personal health information. We are required by law to maintain the privacy of health information that could reasonably be used to identify you, known as “protected health information” or “PHI”.
