Rescue Billing Information Form

We are now accepting Rescue Billing Incident Forms online.
Once the incident is submitted, it will be directly sent to DMMS and entered for billing. To complete the online form, please have the incident report in front of you.
-- All the information with an asterisk is required to begin the billing process
-- Please fill out as much of the form as you can to ensure proper billing and payment.
-- We stress the importance of sending the Vehicle Insurance Information so we can expedite the billing process.
If you have questions concerning your access, please contact us at ITSupport@dmms.us, or call 302-283-3300.

Incident Information

Fire Company Name

 
Incident Date

 
Incident Number

 
Alarm Time

 

EMS Unit

 
                   Level of Rescue




 
Incident Location

 
Incident City

 
Incident State

Rescue Services Provided / Equipment Used

  QTY.   QTY.   QTY.
Hand Lights (Each) Step Chocks (Set/4) Combi-Tool
Axe / Haligan Bar 2 x 4 Cribbing Spreaders
Glass Master 4 x 4 Cribbing O-Cutters
Saw-Zall Stabilization Struts Pedal Cutter
Tool Box Chains Small Rams
Thermal Imager Com-a-long Large Rams
Scene Lighting (mins) Hose Line Portable Power Unit
Debris Removal (mins) Secure Battery Mounted Power Unit
Oil Dry (Bags) CO2 Extinguisher Air Bags
Extrication Time Dry Chem Extinguisher Air Tools

Patient/Owner Information

Patient Name(s)
If from same vehicle, 1 form per vehicle, even if PRS or transported by another agency.

 

Patient Phone Number
(xxx-xxx-xxxx)

 
 
Patient Address(es)

 
Vehicle Insurance Company

 

Policy Number

 
Insurance Agent Name

 

Insurance Agent Phone Number
(xxx-xxx-xxxx)

 
 

Other Information

Vehicle Information VIN Number

 
Officer’s Name

 
Date Completed

 
Your Name

 
Your Phone Number
(xxx-xxx-xxxx)

 
 
Your Email Address

 
 
Question/Comment

 
Disclaimer and Terms of Use

Please Read the USER AGREEMENT Carefully Before Continuing

If you do not receive an acknowledgment from us within two business days, please email us at rescuebill@dmms.us or call 302-283-3300 to ensure your submission was received.

This site is committed to protecting your privacy. Security measures for this site have been taken to protect against loss, misuse or alteration of the information you provide; and industry standard encryption methods are used to assure security. Nevertheless, it is crucial that, as a user, you protect against unauthorized access to your password and to your computer and that you always sign off when finished using a shared computer. Further, you should be aware that no system is impenetrable. Thus, it is your responsibility to diligently monitor your personal information so as to discover and address as quickly as possible any misuse of your personal information.