The City of Pikeville Ambulance Service billing rates are set as follows:
Item or Application of Device | Price |
Item or Application of Device | Price |
Mileage | $14.00 |
Base rate emergency | $1,500.00 |
Base rate non-emergency | $600.00 |
Base rate return trip after receiving medical treatment when medically necessary | $600.00 |
Oxygen | $45.00 |
Waiting time per hour after one hour | $100.00 |
Extrication equipment for all type and technical rescue (when used) | $600.00 |
Trauma disposable supplies | $250.00 |
Basic life support disposable supplies | $150.00 |
The following forms shall be the standard form adopted by the city and shall be used for all ambulance runs.
CITY OF PIKEVILLE AMBULANCE SERVICE RUN#
SCENE MILEAGE
DESTINATION MILEAGE
(_) Mileage
(_) Base Rate, Emergency
(_) Base Rate Non-Emergency
(_) Oxygen
(_) Waiting time per hour after 1 hour
(_) Extrication equipment of all types and Technical Rescue (when used)
(_) Trauma \ Disposable Supplies
Trauma\Disposable Supply Protocol
When you have a patient that gets 2 or more of the following items from your unit there will be a "Trauma\disposable charge".
(Please Circle each item used)
Items:
Bag valve mask
Combo pads
Combi-tube
Splinting (all types)
Mast trousers
C-collar
CID
Long Spine Board Kendrick's Extrication Device
Notes
Run#
INSURANCE INFORMATION
Responsible Party SS#
Medicare UMWA
Medicaid Black Lung
Commercial Carrier (or) Worker's Compensation
Address Policy#
Group
Commercial Carrier (or) Worker's Compensation
Address Policy#
Group
Auto Insurance Carrier
Address Phone#
Agent's Name
Insured's Name Claim #
Insured's Policy #
NON-EMERGENCY TRANSPORT AUTHORIZATION
Medical Transportation services were provided on / / for the patient named below: by The City of Pikeville Fire Department Ambulance Service.
I verify the patient named below was at my office/facility to receive a medical service on / /
(Medical Provider Signature)
I certify that I have received the above described services by The City of Pikeville Fire Department Ambulance Service.
(Recipient Signature)
(Ord. 0-04-020, passed - -04; Am. Ord. 2008-008, passed 1-28-08; Am. Ord. 0-2013-007, passed 4-8-13; Am. Ord. 0-2017-27, passed 9-25-17)