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*

MonthDay Year
Important Information
Email Address*

Confirmation Email
Patient Information
Patient Name*

First Name Last Name
Date of Birth*

Month Day Year
Social Security Number*
Please enter in form of XXX-XX-XXXX
Phone Number*

Area Code Phone Number
Alt. Phone Number

Area Code Phone Number
Address*

Street Address

Street Address Line 2

City State / Province

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

Area Code Phone Number
Insurance Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Adjuster's Name

First Name Last Name
Adjuster's Phone

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

Area Code Phone Number
Insurance Address (Add.)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Adjuster's Name (Add.)

First Name Last Name
Adjuster's Phone (Add.)

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