If you would like to appeal an EMSF program claim, please use this form and
submit it to:
PROVIDER APPEAL RESOLUTION REQUEST
PROGRAM: EMSF
Provider Name: ________________________________________________________________________________
Provider Tax Id #: ______________________________________________________________________________
Provider Address: ______________________________________________________________________________
____________________________________________________________________________________________
CLAIM INFORMATION:
(please use one form per claim)
Patient Name:__________________________________________________________________________________
Date of Birth:___________________________________________________________________________________
Patient ID Number:______________________________________________________________________________
Patient Account Number:__________________________________________________________________________
Claim No:_____________________________________________________________________________________
Service From/To Date:____________________________________________________________________________
Claim Amount Billed:_____________________________________________________________________________
Description of Appeal:____________________________________________________________________________