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Omni EMS Billing
111 Whittier
Wichita, KS 67207
phone: 316.689.3537 | fax: 316.689.3556 | toll-free: 866.248.1189
buff@groupomni.com

Please provide us with the following information so that we might
better understand your organization's billing needs:


* REQUIRED FIELDS
* Contact Name:
  Title:
* Service Name:
* Mailing Address:
* City:
* State:
* Zip:
* Phone:
  Fax:
  E-mail:
  How did you find us?

Referral  Expo

Mailing    Internet    Other

Type of Service
You Provide:

ALS   ALS2 Facility Transport

BLS    AIR

Monthly # of Runs

 

Why do you think you need our service?


 

Please indicate the best time and method for a
customer service representative to contact you.


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