This government document is issued by Department of Health for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:-o2sxg2obgu&q=https://www.health.pa.gov/topics/Documents/EMS/EMSIB%25202018-21%2520Direct%2520Pay%2520Notice%2520of%2520form%2520publication.pdf&sa=U&ved=2ahUKEwjL94uCtdD8AhWqVaQEHR-wAvM4WhAWegQIABAC&usg=AOvVaw2UN3Gt39PtmUI2cHsljJmM