Insurance Information Form Complete your insurance information below so that we may qualify you. Allow one business day for processing. Secure: This link is secure. Information will not be used for any other purpose. Get Started Now It only takes seconds… You could save hundreds! PB-MOT Online Form Insurance: - Select One - HMO - Private Insurance PPO - Private Insurance HMO - Blue Cross Blue Shield PPO - Blue Cross Blue Shield Medicare Medicaid Not Sure Cash Best Time To Call: Anytime Morning Afternoon Evening Submit * Please complete all fields before submitting form. By submitting this information, I authorize Americare Respiratory Services, Inc., affiliates, subsidiaries, or parent company to contact me by phone. Rest assured that we value and protect your privacy and do not share your information with third parties.