Title: Reporting Requirements Regarding Air Ambulance Services – Providers of Air Ambulance Services

OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx

Air Ambulance Data Report Instructions – Providers of Air
Ambulance Services
Background & Purpose
Section 106(a) of the No Surprises Act, which was enacted as part of the Consolidated Appropriations Act, 2021, requires providers of air ambulance
services to submit data on air ambulance services to the Secretary of Health and Human Services and the Secretary of Transportation (the
Secretaries). The Department of Health and Human Services (HHS) proposed implementing regulations at 45 CFR part 149. The Centers for Medicare
and Medicaid Services (CMS) is collecting these air ambulance data on behalf of the Secretaries.
These are the Instructions for the Air Ambulance Data Report (AA Report). The purpose of this document is to provide instructions and definitions for
submission of the required air ambulance data to CMS. The required data elements are described in the proposed 45 CFR 149.460. These
Instructions provide information on the organizational responsibility for reporting, the deadlines and reference period for the data submission,
definitions, instructions for the specific data fields, and the submission process.

Applicability of Reporting Requirements
These reporting requirements apply to all providers of air ambulance services subject to section 106 of the No Surprises Act. A provider of air
ambulance services means an entity that is licensed under applicable State and Federal law to provide air ambulance services. 1 An air ambulance
service means a medical transport by a rotary-wing air ambulance, as defined in 42 CFR 414.605, or fixed-wing air ambulance, as defined in 42 CFR
414.605. The responsible entity may engage a third party to submit the air ambulance data on their behalf. We refer to the entity that submits the
data to CMS as the submitting entity.
The primary basis for reporting is at the National Provider Identifier (NPI) level. The responsible entity is the organization corresponding to the NPI.
For example, if the responsible entity is a not-for-profit health care organization associated with the NPI, and provides air medical staff, supplies, and
services but contracts with a separate for-profit organization for air medical transportation services, the health care organization is responsible for
the submission of the air ambulance data to CMS.
This includes municipality-sponsored providers, the tribally-operated program in Alaska, and public agency programs that provide on-demand air ambulance
services regionally, pursuant to the Federal Aviation Regulation 14 CFR parts 119 and 135.

1

Deadlines and Reference Period for Data Submission
The AA Report reflecting the data for the 2022 calendar year reporting period must be submitted to CMS by March 31, 2023. The AA Report
reflecting the data for the 2023 calendar year reporting period must be submitted to CMS by March 30, 2024. The AA Report must include data
relevant to air ambulance services furnished within the reporting period, as well as data relevant to air ambulance services with payment dates that
fall within the reporting period.

Submission Process
The data collection system for air ambulance data is under development. CMS will update both the information collection section of the rule
and these instructions, as well as provide additional guidance regarding the submission process, once the technical development of the data
collection system has been completed.

Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of
Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to
complete this information collection is estimated to average 147 hours per response, including the time to review instructions, to make IT changes to
collect, consolidate and report the required information, in the required format, to HHS. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop
C4-26-05, Baltimore, Maryland 21244-1850.

Organization Information
This section collects identifying information about your organization, the NPIs used by your organization, and the air ambulance bases associated with
those NPIs.
Table 1. Air Ambulance Organization Information
Item
Number
O1
O2
O3
O4
O5
O6
O7
O8
O9
O10
O11
O12
O13
O14

Data Element

Instructions

Reporting Period
Submitting Entity Name
Submitting Entity FEIN
Submitting Entity Point of Contact: Name
Submitting Entity Point of Contact: E-mail
Responsible Entity Name
Responsible Entity FEIN
Responsible Entity Point of Contact: Name
Responsible Entity Point of Contact: E-mail
Address: Street
Address: City
Address: State
Address: Zipcode
Organization Type

O15

Parent Company Name

O16

Parent Company FEIN

O17

Number of Bases

O18

NPIs

Enter 2022 or 2023, as applicable.
Enter the name of the entity submitting the data.
Enter the FEIN of the entity submitting the data.
Enter the name of the point of contact for the entity submitting the data.
Enter the email address for the point of contact for the entity submitting the data.
Enter the name of the responsible entity.
Enter the FEIN of the responsible entity.
Enter the name of the point of contact for the responsible entity.
Enter the email address for the point of contact for the responsible entity.
Enter the street portion of the address for the responsible entity.
Enter the city portion of the address for the responsible entity.
Enter the state portion of the address for the responsible entity
Enter the zipcode portion of the address for the responsible entity
Select the description of organization type that best fits:
• For-Profit
• Not-for-Profit (excl. government)
• Government (federal, state, local (county, city/township, other municipal)
• Public-Private Partnership
• Enter the name of the parent company, owner, other proprietor, or sponsor
of the responsible entity. If none, enter “None.”
Enter the FEIN of the parent company, owner, other proprietor, or sponsor of the
responsible entity. If none, enter “None.”
Enter the total number of air ambulance bases operated by the responsible entity (or
by the air carrier used by the responsible entity).
List all National Provider Identifiers (NPIs) used by the responsible entity to bill for air
ambulance services.

Base Information
This section collects information about each air ambulance base.
Table 2. Air Ambulance Base Information
Item
Number

Data Element

B1
B2
B3
B4
B5

LOCID
Base Name
Base City
Base State
Delivery Model

B6

Number of Payor Contracts

B7

Names of Contracted Payors

B8

Air Medical Subscriptions or
Ambulance/EMS Membership Programs

B9

Non-Direct Payor Contracts

B10

Are Operational Costs Shared with Others

B11

Does the Base Operate Ground Ambulances

Instructions
Enter the Location Identifier (LOCID) as provided in Airport Master Record Form 5010.
(If no LOCID is available, contact CMS for instructions.)
Enter the name of the air ambulance base.
Enter the city portion of the address for the air ambulance base.
Enter the state portion of the address for the air ambulance base.
Select the service delivery model that best fits this base:
• Independent
• Hospital-owned or sponsored
• Hospital-Independent Partnership (hybrid)
• Municipality-sponsored (include public agency programs)
• Tribally-operated Program in Alaska
Enter the number of direct contractual relationships with a group health plan or
health insurance issuer to furnish air ambulance services associated with this base
that existed during the reporting period.
List the names of all group health plans and health insurance issuers with which the
responsible entity contracted to furnish air ambulance services associated with this
base.
Select Y/N to indicate whether the responsible entity had any air medical subscription
or ambulance/EMS membership programs associated with this base during the
reporting period.
Select Y/N to indicate whether the responsible entity had any non-direct payor
contracts associated with this base during the reference period.
Include waiver, rental, lease, supplemental agreements, and similar arrangements.
Select Y/N to indicate whether any operational costs of this base, such as building
space or personnel, are shared with operations other than the air ambulance services
(for example, hospital facilites).
Select Y/N to indicate whether ground ambulance services are operated out of this
base.

Item
Number
B12

Data Element

Instructions

Total Number of Responses

B13

Number of Non-Transport Responses

Enter the total number of air ambulance responses provided from this base during
the reporting period.
Responses include any time the organization arrived at the scene, regardless of
whether it was dispatched or whether the response resulted in an air ambulance
transport.
Enter the total number of air ambulance responses that did not result in a scene
response patient transport, an inter-facility transport, or an
organ/personnel/equipment transport during the reporting period.

Base – Vehicle Information
This section collects information about each aircraft at each base location. Include all aircraft operated out of the base, regardless of the purposes for
which the aircraft is used.
Table 3. Air Ambulance Vehicle Information
Item
Number
BV1
BV2
BV3
BV4

Data Element

Instructions

LOCID
Base Name
Aircraft N-Number
Aircraft Type

BV5

Aircraft Use

BV6

Flight Equipment

BV7

Number of Scene Response Patient Transports

BV8

Number of Inter-Facility Patient Transports

BV9

Number of Other Transports

BV10

Average Number of Flight Staff

BV11

Average Number of Medical Staff

From B1.
From B2.
Enter the N-Number assigned to the aircraft.
Indicate whether the aircraft is
• Fixed-wing
• Rotary
Indicate the primary use of this aircraft:
• The aircraft is in active regular use for air medical transports
• The aircraft is used for back-up operations
• The aircraft is used for other purposes
Select Y/N to indicate whether the aircraft is equipped for Instrument Flight
Rules.
Enter the number of scene response patient transports conducted during
the reporting period.
Enter the number of inter-facility patient transports conducted during the
reporting period.
Enter the number of transports of organs, medical personnel, or medical
supplies conducted during the reporting period.
Indicate how many flight staff are used on average per patient transport on
this aircraft.
Indicate how many medical staff are used on average per patient transport
on this aircraft.

Labor Costs
This section collects information about the labor costs associated with the air ambulance base, as well as associated with the regional
and corporate offices, if any. Please include information related to all NPIs associated with this base.

Response Staff

Report information about Response staff (including full- and part-time) at this base, including:
• Annual compensation for all paid response staff by category
• Total hours worked annually by paid response staff by category, including hours for activities other than air ambulance services
Please review the following instructions:
• If operational costs are shared with another entity, then include only paid response staff who had responsibilities that
were either partly or entirely related to the air ambulance base, including frontline staff responding to air ambulance calls.
• If operational costs are shared with another entity, then do not include individuals with only non-air ambulance
responsibilities (for example, firefighters who are not EMT or response staff).
• If this base operates a ground ambulance service, then do not include individuals who had only ground ambulance
responsibilities.
• Report paid staff with primary response responsibilities in the appropriate response category and not in any other
category. For example, response staff who had supervisory or administration/facilities responsibilities in the response
staff category, and do not also count these staff in the administration/facilities category. In this example, a pilot with
vehicle maintenance responsibilities should be included in the pilot category but not in the vehicle maintenance
category.
• Include medical directors in the administrative/facility category and not in the response physicians category unless they
primarily have response responsibilities.
• In the administrative staff category, include clerical, HR, billing, and IT support.
• Benefits include but are not limited to life insurance, vacation and holiday time off, medical and dental coverage, shortand long-term disability, and retirement contributions (such as pension or 401(k)).
• If labor is provided through contracts with third-party vendors, report these costs in the Vendor section or for Aviation
contracts under the Vehicle Costs section and provide comments in the Comments section.
For Annual Compensation
• Report labor costs for each of the following cost categories (salaries/wages, incentive compensation, benefits, workers
compensation, payroll taxes (FICA), and other costs) for paid staff in each of the response staff categories in the table
below.
• If one or more components of compensation costs (e.g., benefits) were paid by another entity with which you had a

business relationship (e.g., a county or municipality that you serve), obtain and include these costs when you report labor
costs. If only total costs in a category are available from another entity (e.g., total benefits costs across all staff), allocate to
labor categories based on salary or wages across labor categories. For example, if total benefits were $60,000, one-third of
salary and wages was for Paramedic(s) and two-thirds of salary and wages was for Nurse(s), then $20,000 ($60,000
multiplied by one-third) would contribute to total compensation for Paramedic(s) and $40,000 ($60,000 multiplied by twothirds) would contribute to total compensation for Nurse(s).
For Total Hours Worked Annually
• Please report total hours worked by paid response staff (including full- and part-time staff) in each category annually. For
example, if your organization has two paid paramedics who both work 2,000 hours annually (i.e., full time at 40 hours a
week for 50 weeks), and two paid paramedics who each work 1,250 hours annually (i.e., part time at 25 hours a week for 50
weeks), the reported hours would sum to: 2,000 + 2,000 + 1,250 + 1,250 = 6,500 hours for paramedics.
• Report total hours worked, on air ambulance activities only, by paid staff with some or entirely air ambulance
responsibilities. As an example, for a paid firefighter/paramedic who worked 2,000 hours annually (i.e., full time at 40
hours a week for 50 weeks) across fire and air ambulance operations, report the share of hours related to air ambulance
services.
• Do not include paid or unpaid time off (e.g., vacation, sick leave, etc.) or hours spent on fundraising when reporting total
hours worked annually.
• If this base operates a ground ambulance service, do not include hours dedicated to ground ambulance activities.
• Include only staff whose roles are with your base. If staff are employed as paramedics with your base and as
firefighters for another organization, include only the paramedic hours for your base.

Administration and Facilities Staff
Please review the following instructions before completing the table below.

•

Report individuals with any air ambulance response responsibilities in the appropriate response category and not in
the administration/facilities category. Please do not report costs for response staff in the administration/facilities staff
categories even if they sometimes perform administration/facilities duties. For example, a pilot with vehicle
maintenance responsibilities would contribute to the appropriate response category but not to the vehicle
maintenance category. For administration/facilities staff with multiple roles, assign each individual to a category
indicating the individual’s primary activity. For example, if an individual performed primarily management duties but
also had billing or pre-billing duties, include the individual in the management category.

•

For the base level rows, include only paid administration/facilities staff who had responsibilities that were either partly
or entirely related to your air ambulance base.
o If operational costs are shared with another entity, then do not include individuals with only non-air ambulance

•
•

responsibilities (for example, firefighters who do not have air ambulance management responsibilities).
o If this base operates a ground ambulance service, then do not include individuals who had only ground
ambulance responsibilities.
Costs borne at the regional and corporate levels should be pro-rated across all bases operated by your organization.
Report Regional and Corporate Level labor costs in this section if accounted for separately; otherwise report in the
Overhead Costs section and describe in the Comments section.

Facility Costs

This section collects information about the facilities costs associated with this air ambulance base as well as with the regional and corporate offices.
Please review the following instructions:
• In the base level table, include information related to all NPIs associated with this base.
• In the base level table, report the allocated portion of lease or ownership facilities costs incurred at the level of your parent
organization/central or regional office (e.g., corporate or regional buildings, garages or service facilities serving multiple bases) but located at
this base location using your organization’s approach for allocating annual costs to specific bases. Please describe your approach for
allocating these facilities costs across air ambulance bases in the Comments section.
• In the regional and corporate columns, report costs related to facilities used at the regional and corporate levels respectively.
• Include costs paid by another organization or entity on your organization’s behalf.
• Include costs for facilities that were partially related to ground ambulance operations, if applicable. Do not include costs for facilities that are
solely used for ground ambulance operations.
• Exclude donations or exceptions for which there was no cost.
• Do not report depreciation if your organization does not capitalize facilities for accounting purposes. Please make a note of this in the
Comments from Providers section.

Vehicle Costs
This section collects information about the vehicle costs for vehicles located and used at the air ambulance base as well as about the vehicle costs for
the regional and corporate offices.
Please review the following instructions:
• Include information related to all NPIs associated with this base.
• For owned vehicles, do not report depreciation if your organization accounts for vehicles on a cash basis.
• If aviation services are outsourced, include costs of outsourcing under Aviation Vendor Fees and provide detailed information in the
Comments section on what is covered by the vendor (e.g., all vehicle maintenance, including labor, parts and supplies).
• If your organization calculates depreciation expense for multiple purposes (e.g. depreciation for tax incentive purposes vs. Generally Accepted
Accounting Principles (GAAP) for standard auditing purposes), report the depreciation expense captured for standard auditing purposes.
Please note the method used to calculate depreciation expense in the Comments section.
• To the extent that parts or maintenance is specific to an air ambulance vehicle, report per associated vehicle. Otherwise, provide total cost of
maintenance equipment across all vehicles in Total column. Do not include any in-house labor costs already included in the labor section or
any outside service or contract costs reported under Aviation Vendor Fees.
• For each piece of capital medical equipment on the air ambulance include total costs including depreciation, maintenance, certification, and
service costs.
• Provide a description of the capital medical equipment in the Comments section.
• In the regional/corporate columns, report the allocated portion of non-air ambulance vehicle costs incurred at the level of the parent
organization/central or regional office but used and located at this base using your organization’s approach for allocating costs to specific
bases. Describe the cost allocation method in the Comments section.
o If you do not allocate non-air ambulance vehicle costs, report in the Regional and Corporate column.

Equipment, Consumable, and Supplies Costs
This section collects information on equipment, consumables, and supply costs.
• Use your organization’s guidelines to categorize goods as capital expenses versus operation expenses and report
depreciation.
• Do not report depreciation if your organization uses a cash basis for accounting.
• Do not include medical equipment that is installed in the air ambulance and reported under vehicle costs in
this section. Include costs of medications, medical equipment, supplies and consumables (such as gauze,
gloves, bandages, basins, oxygen, sterile water, stethoscopes, blood pressure cuFee-for-Service, IV supplies,
etc.) in the appropriate row.
• Capital medical equipment refers to equipment that can endure repeated use; it includes, but is not limited
to, defibrillators, ventilators, monitors, and power lifts.
• For capital expenditures, medical and non-medical equipment, most organizations will amortize costs over
the life of the good.
• For capital expenditures (medical and non-medical equipment), report annual depreciation expenses. If your
organization calculates depreciation expense for multiple purposes (e.g. depreciation for tax incentive
purposes vs. Generally Accepted Accounting Principles (GAAP) for standard auditing purposes), report the
depreciation expense captured for standard auditing purposes. Describe the method used to calculate
depreciation expense in the Comments section.
• For leased capital goods and medical and non-medical equipment, the annual cost is the annual lease expenditures for
the piece of equipment.
• For all of the cost categories: if you have an ongoing relationship with an organization that pays this cost for your
organization, report the cost here.
• Do not include costs for donated items.
• Do not include costs for equipment, consumables or supplies used on ground ambulances.
• Report the allocated portion of non-medical equipment and supply expenses incurred at the level of the parent
organization/central office and used at this base using your organization’s approach for allocating costs to specific
bases. Describe the cost allocation method in the Comments section.
• Do not include any “central office equipment” that serves multiple NPIs, except for where specifically requested.
These amounts should be reported in the regional/corporate-level columns.

Vendor Costs
This section collects information about costs for services that are provided through contracts with vendors and that have not been reported in the
previous sections. For example, your organization may contract with an outside vender for dispatch/call center services.
•
•
•
•

If any of the service categories are not contracted out, enter “0” (zero).
If these services are shared or provided by the ownership arrangement (i.e., hybrid model hospital/independent or public/private
partnership), obtain the costs from the responsible party.
Report the allocated portion of these services incurred at the level of the parent organization/central office for this base using your
organization’s approach for allocating costs to specific bases, if applicable. Describe the cost allocation method in the Comments section.
Do not include any “central office” vendor costs that serve multiple NPIs, except for where specifically requested. These amounts should be
reported in the regional/corporate-level column.

Overhead Costs
This section collects information on the costs for overhead (non-facility) services used at the base and at the regional and corporate levels, that have
not been reported in the previous sections.
•
•
•
•
•

If these services are shared or provided by the ownership arrangement (i.e., hybrid model hospital/independent or public/private
partnership), obtain the costs from the responsible party and report.
Training and continuing education costs include but are not limited to costs for materials, travel, training fees, and labor. Do not include any
labor costs associated with training that were already covered by standard labor costs in the Labor Costs section.
Report overhead costs for these services incurred at the level of the parent/organization/central office that are not allocated at the base level
in the Regional and Corporate column.
Report the allocated portion of these services incurred at the level of the parent organization/central office of this base using your
organization’s approach for allocating costs to specific bases. Describe the cost allocation method in the Comments section.
In the base-level column, do not include any “central office” overhead non-facility costs that serve multiple NPIs, except for where specifically
requested. These amounts should be reported in the regional/corporate-level columns.

Revenue – Air Ambulance Transports
This section collects information on overall revenues from paid air ambulance transports at the base level.
•
•
•

Include payments for transports from all payors (primary, secondary, etc.).
Include all payments collected, including cost sharing and ancillary fees for specialty services.
Include revenues collected during the entire respective reporting period (i.e., calendar year 2022 to be submitted by March 31, 2023 and
calendar year 2023 to be submitted by March 30, 2024).

Revenues – Other Sources

This section collects information on revenues from sources other than from paid transports at the base, regional, and corporate levels.
•
•
•
•
•

Include cash or in-kind donations (i.e., donations of vehicles or equipment)
Include membership/subscription program revenues that are operated as entities that are separate from your organization, but are related.
Revenue from payors for EMS services other than transports includes transports of organs, medical personnel, supplies, or equipment.
Funding grants and government funding includes special purpose and matching grants (generally, state), demonstration grants (generally,
federal).
Report the allocated portion of other sources of revenue received at the level of the parent organization/central office for this base using
your organization’s approach for allocating costs to specific bases, if applicable. Describe the cost allocation method in the Comments
section.

Transport Data
This section collects data on each air ambulance transport provided or reimbursed during the reporting period.
•

For each transport, provide the line-level detail or header-level detail as required by the data element. For example, there may be several
CPT/HCPCS code(s) and modifier(s) per transport. The data collection instrument will be set up to enable reporting of a list of all CPT/HCPCS
codes and modifiers related to a transport.

Item
Number
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10

Data Element

Instructions

LOCID
Base Name
Aircraft N-Number
Date of Service
NPI
NPI Street Address
NPI City
NPI State
NPI Zipcode
CPT/HCPCS Code

T11
T12
T13
T14
T15

Loaded Statute Miles
Pick-up Location Zipcode
Drop-off Location Zipcode
Duration of Flight (HH:MM)
Primary Payor

From B1.
From B2.
From BV3.
Enter the date of the transport.
Enter the National Provider Identifier (NPI) used for billing for this transport.
Enter the street address for the NPI holder used for billing for this transport.
Enter the city for the National Provider Identifier used for billing for this transport.
Enter the state for the National Provider Identifier used for billing for this transport.
Enter the zipcode for the National Provider Identifier used for billing for this transport.
List all CPT/HCPCS codes related to this transport. Include CPT/HCPCS modifiers in parentheses next to
the respective CPT/HCPCS code.
Enter the number of loaded statute miles for this transport.
Enter the pick-up location zipcode for this transport.
Enter the drop-off location zipcode for this transport.
Enter the duration of the flight.
Select the primary payor for this transport:
• Medicare Fee-for-Service
• Medicare Advantage
• Medicaid
• TRICARE
• Veterans’ Health Administration
• Indian Health Service
• Group Health Plan
• Commercial Health Insurance Issuer
• Federal Employees Health Benefits Plan

Item
Data Element
Number

Instructions
•
•
•

Workers’ Compensation
Patient Cost Sharing
Patient Self-Pay

Group health plan includes self-funded employers other than those included in the other categories (such
as a private employer or a state or local government). Commercial health insurance issuer typically
includes insurance companies.
Enter the name of the group health plan, health insurance issuer, or other payor for this transport with
whom the responsible entity had a contract to provide air ambulance services in effect prior to the
transport.

T16

Contracted Payor Name

T17

Non-Direct Contract Type

T18

Emergent Transport

T19

Transport Type

T20
T21

Was Claim Denied?
Denial Reason

T22

Was Claim Denial Appealed? Select Y/N to indicate whether the claim denial was appealed.

T23

Was Claim Paid after
Appeal?
Submitted Charge – Base
Rate

T24

Select the type of non-direct contract with the payor:
• Wrapper
• Lease
• Rental
• Supplemental
• Single Case Agreement
• Other
Select Y/N to indicate whether the transport was deemed emergent or not.
Select the transport type:
• Scene Response Patient Transport
• Inter-Facility Patient Transport
• Other
Select Y/N to indicate whether the claim submitted to the payor was denied.
Enter the denial reason code.

Select Y/N to indicate whether the denied claim was paid after appeal.
Enter the amount of the submitted base rate charge for this transport.

Item
Data Element
Instructions
Number
T25
Submitted Charge – Mileage Enter the amount of the submitted mileage charge for this transport.
T26
Submitted Charge – Other
Enter the amount of submitted charges not included in the base rate and mileage charges for this
transport. Other submitted charges include payments for intervention or ancillary services such as
oxygen administration, blood administration, ultrasound, etc. These services would have unique
CPT/HCPCS codes (such as A0422 for oxygen administration or 86900 for blood administration).
T27
Paid Amount – Base Rate
Enter the amount paid by the primary payor for the base rate for this transport.
T28
Paid Amount – Mileage
Enter the amount paid by the primary payor for the mileage for this transport.
T29
Paid Amount – Other
Enter the amount paid by the primary payor for other charges.
T30
Paid Amount – Other Payors Enter the total amount paid by all secondary payors for this transport. Do not include patient cost
sharing.
T31
Patient Cost Sharing
Enter the cost sharing amount received from the patient for this transport. Cost sharing is the amount
Amount
for which the patient is responsible under the group health plan or health insurance coverage agreement.
Cost sharing does not include balance-billed amounts. If patient is the sole payor, do not report patient
self-pay amount here.
T32
Amount Billed to Patient
Enter the amount of the bill sent to the patient for this transport.
T33

Was Bill Referred to
Collections?
Amount Received from
Patient

Select Y/N to indicate whether the bill sent to the patient was sent or sold to a collector or otherwise
referred for collection action, including lawsuits, wage garnishments, or liens.
Enter the total amount received from the patient for this transport, including through regular bill
payment or collections; include cost sharing amounts. Include third-party payments of amounts billed to
the patient.

T35

Other Reimbursement

T36

Type of Other
Reimbursement

Enter the amount of any other reimbursements received for this transport that have not been reported
in other categories.
Describe the type(s) of other reimbursements received for this transport, such as subscription or
membership programs.

T34