Patient Services

Request Run Number

Your EMS incident run number is required to pay your bill through EMSMC Secure Pay. Use this form to request it from Millstadt Ambulance Service.
A member of our team will respond to your request with your run number as soon as possible. Identity verification is required by law.

Patient Information

Patient First Name *

Patient Last Name *

Date of Birth *

Date of Service *

Contact Information

We will respond to your request using the contact information below.

Phone Number *

Email Address *

Relationship to Patient *

HIPAA Authorization & Identity Verification

Authorization for Release of Protected Health Information

I hereby authorize Millstadt Ambulance Service to release the EMS incident run number associated with the emergency medical services call described above, for the sole purpose of facilitating online bill payment through EMSMC Secure Pay.

I certify that I am either (a) the patient named above, or (b)the patient's legally authorized representative with full legal authority to access and act upon the patient's protected health information as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. § 164.508.

I understand and acknowledge the following:

This authorization is voluntary. I may refuse to sign without affecting my right to receive treatment or services from Millstadt Ambulance Service.
I may revoke this authorization at any time by submitting a written request to Millstadt Ambulance Service, except to the extent that action has already been taken in reliance upon it.
The information released pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected under HIPAA once disclosed.
This authorization is strictly limited to the release of the EMS incident run number associated with the date of service specified above and no other protected health information.
Millstadt Ambulance Service reserves the right to verify my identity before responding to this request.

Federal Law Notice — Penalty for False Statements

I understand that providing false, fictitious, or fraudulent statements or representations in connection with this request constitutes a violation of federal law, including but not limited to 18 U.S.C. § 1001 (False Statements), and may result in criminal penalties including fines and/or imprisonment of up to five (5) years. Misrepresenting my identity or authorization to access another individual's protected health information may also constitute a violation of HIPAA (42 U.S.C. § 1320d-6), punishable by civil and criminal penalties.

I have read and fully understand the above authorization. I certify under penalty of law that all information provided is true and accurate to the best of my knowledge, and that I am legally authorized to request the protected health information described herein. I consent to the release of my EMS incident run number to the contact information provided above.

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A member of our team will respond with your run number as soon as possible. Do not submit this form on behalf of another person without proper legal authorization.