Please submit your ambulance billing and medical care concerns using the following form; the Monterey County Emergency Medical Services (EMS) Agency will get back to you as soon as possible.

This form can also be used for positive feedback and general questions about the EMS System.

Contact Information

Name: (Required!)
Address: (Required!)
Phone: (Required!)
-
E-mail: (Required!)


Claim Information

Subject (Required!)
EMS Service Provider: (Required!)
Incident Location: (Required!)
Incident Date: (Required!)
Invoice / Account Number:
EMS Patient Care Report Number (PCR)
Patient Name On PCR: (Required!)
Description Of Problem: (Required!)