Home
Ambulance
Aeromedical
About LifeNet
Injury Prevention
History
Employment
Resources
Links
Questions
Customer Inquiries
LifeNet Stars of Life
Employee Information
Employee Intranet
Employee OWA Email
Education Opportunities
Hospital Resources

LifeNet, Inc.

 

Texarkana
6300 Hampton Rd
Texarkana, Texas 75503
(903) 832-8531
(800) 832-6395

Hot Springs
220 Ouachita St.
Hot Springs, Arkansas 71901
(501) 624-4206

 

 

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 both Adobe Acrobat (PDF) and in Microsoft Word (Word)

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.
 
 
2007 Subscription Form

PDF
 

 
 
 
 
 
 

Home | Ambulance | Aeromedical | About LifeNet | Resources | Employee Information | Hospital Resources