16945 Sherman Way
Van Nuys, CA 91406
(818) 996-2200

Home CompanyServicesEquipmentDispatchBillingCareersLinksContact

Insurance Submission
* Required fields
Patient Information
*Patient First / Last Name:
*Ticket Number:
*Date of Services: mm/dd/yyyy
*Patient's DOB: mm/dd/yyyy
Patient's Address:
Patient's City
Patient's State
Patient's Zip
*Patient's Phone: (including area code) (xxx-xxx-xxxx)
Insurance Information
Insurance Provider:
Insured's Name:
Date Issue: mm/dd/yyyy
Insured Employer:
Insured I.D. Number:
Insured Group:
Employer Phone: (including area code) (xxx-xxx-xxxx)
Credit Card Information
Credit Card Type (V)/(M)/(D):
Card Holder's Name::
Credit Card Number:
Expiration Date:
CSC: (Card Security Code)
Billing Information
If Billing address is the same as above click here
Billing Address:
Billing Phone: (including area code) (xxx-xxx-xxxx)
Billing City
Billing State