Patient Advocate

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Patient Name

DOT

FV Number

Best Contact Phone Number

Patient Address

Can we call you at work Y or N

Work Phone number

Your Email

Insurance Name

ID Number

Insurance Phone Number

Do you have secondary Insurance you want bill?

Secondary Insurance

ID Number

Secondary Insurance Phone Number

Your Classic Billing Specialist based on your last name is:
A-G direct phone number is 801-383-3689
H-O direct phone number is 801-383-3861 Ext 141
P-Z direct phone number is 801-383-3686

Please let us know of anything you feel would help in the care you received or in
the future processing of your insurance claim you feel our clinical, billing, or
administrative staff needs to know:

Our clinical staff would like to thank you for your feedback regarding your flight, and making us aware of any special insurance situations or concerns you may have that can be addressed immediately. Our office strives from the beginning of every transport to the very end to help you and your loved ones in this time of need. This form can be completed and returned to the corresponding email address above (based on your last name), faxed to 801-443-1993, or mailed to Classic Air Care 1010 North 500 East #200, North Salt Lake City, UT. 84054-4105. If you have any other concerns those can be directed to the number above or to our website at https://www.classicairmedical.com/. Our general company phone number is 801-295-5700. If you are a member of our membership program and have any questions regarding your flight and membership contract those can be directed to: 1-801-295-5700 Ext 112. To protect your personal information and follow HIPAA policies please return all information to the address below in a secure envelope:
101 N 500 E – Suite 200
North Salt Lake, UT 84054

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