S-SV EMS Ground Ambulance Provider Agency Rates Survey

Agency Name *

Primary Contact Name *

Primary Contact Telephone Number *

Primary Contact Email Address *

Note: only include data for transports originating in the S-SV EMS Region

Total BLS Transports *

Enter 'N/A' if none or not applicable

Total ALS Transports *

Enter 'N/A' if none or not applicable

Total CCT/SCT/Neonatal Transports *

Enter 'N/A' if none or not applicable

Note: please provide the following data for the most recent completed financial reporting year

The following commercial insurance payer mix and collection rate information is for: *

Commercial Insurance Payer Mix % *

Total Ambulance Collection Rate % *

Note: ambulance collection rate means the percentage of revenue actually collected compared to the total amount billed

Maximum BLS Transport Base Rate *

Maximum LALS/ALS Transport Base Rate *

Enter 'N/A' if your agency does not provide this level of service in the S-SV EMS region

Maximum CCT/SCT/Neonatal Transport Base Rate *

Enter 'N/A' if your agency does not provide this level of service in the S-SV EMS region

Maximum Mileage Rate - Per Mile *

What was the effective date of your agency's last ground ambulance rate adjustment? *

How ofter does your agency review and adjust ambulance rates *

Provide a summary of your agency's ambulance rates review/adjustment process *

What positive or negative impacts has your agency experienced from the AB 716 related S-SV EMS ground ambulance rate approval process? *

Please provide any additional comments you have related to this matter (optional)