Hardship Application

This is an application for financial hardship consideration. This application will be utilized to determine eligibility for uncompensated services based on established criteria. By submitting this application you hereby certify that the information provided below is current and accurate to the best of your knowledge. You also certify that you have utilized available agencies (Medicare, Medicaid, and any other commercial insurance) that provide assistance which may be available for payment of your ambulance charges. Payment received from said agencies will be assigned to your ambulance provider. Information provided on this application will be utilized for financial hardship consideration only. Parties privileged to this information will include transporting ambulance provider and third party billing company only.

HardshipApplication&WaiverRequestForm-07212015

Formulario de Información de Seguro para Transporte de Pacientes Para procesar su reclamo, por favor complete el formulario a continuación con la información de su seguro. Solo complete los campos que sean aplicables a su cobertura