LifeNet Forms and Documents
The following forms and documents are made available to assist our patients in obtaining their records and to gain a better
understanding of their patient rights. Documents are available in Adobe Acrobat (PDF)
Completed forms can be faxed to 903-832-0215
Assignment of Benefits - Used when the patient is being represented by an attorney. By signing the patient avoids being
sent to collections and agrees to send us payment upon settlement.
Charity Application - For cases in which a patient is unable to make monthly payments or pay their bills because of
a fixed income or a financial hardship.
Medical Release of Information - To be used if the patient needs their ambulance medical records for a physician's
visit, attorney, social security benefits, etc. Patients are also requested to provide identification when picking up the records.
Privacy Policy
Physicians Certification Statement for Ambulance Services (PCS) - Use by physicians and nurses, the PCS is standard
documentation for ALL non-emergency ambulance transports. The general information at the top of the form, the condition
justifying medical necessity and the physician’s signature at the bottom of the form must be completed for ALL transfers.
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