This is a form you can use to submit insurance directly to our billing company. If you have any questions please call them at 660-829-4046  M-F 8-4. You can also make a copy of your cards and fax them to them at 660-829-4021 or email them to help@colecampems.com

Information that you may want to put in the additional information area is, if this was a car accident, a work related injury and add your employer, or add any other information that you feel may be important. Our mission is to bill your insurance company in the most efficient way to expedite payment.

If you have any questions about this form email help@colecampems.com