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:

* Name:
Title:
* Service Name:
* Mailing Address:
* City:
* State:
* Zip:
* Phone Number :
Fax:
E-mail:
How did you find us?	Referral Expo Mailing Internet Other
Monthly Number of runs
Type of service you provide	ALS ALS2 Facility Transport BLS AIR
Why do you think you need our service?
Please indicate the best time and method for a customer service representative to contact you.

* REQUIRED FIELDS