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First Name*
Last Name*
Job Function	Chief   Battalion/EMS Chief   EMS Director   Finance Biller   Billing Agent   Other
Agency /  Company
Address 1*
Address 2
City*
State*
Zip*
Phone
Email*
*Who does your EMS / Fire rescue billing?       In-house   Outsourced / Billing Agent   Don't currently bill
If you do your own billing (in-house), how many people perform this function?
If you outsource your EMS billing, what company?
*Number of annual transports (estimate):  Total      Billable
Average charge per transport: $
*Do you have a Field Data System?  Yes    No
If yes, which one?