Financial Hardship Application Form - Medicount - Ambulance and EMS billing services and software.

Dear Patient,
Medicount Management provides full or partial financial assistance to patients whose family income is at or under the income guidelines listed below.

Eligibility depends upon:

Meeting income qualifications as outlined below
Application is completed in full
Proof of Income documentation is provided (See below for accepted documentation)

Please complete and sign the enclosed application for financial assistance. The application must be returned complete with supporting documentation for all income in order to be accepted for processing. Please complete each field on the form. If the field does not apply to you enter NA. Examples of acceptable documentation include:

Pay Stubs – 3 months of current paystubs. Or last years tax return/W-2
If you claim to be self-employed, we require a copy of your Schedule C along with a copy of page 1 of the Federal Income Tax return that reflects filing status, dependents claimed and adjusted gross income.
Social Security/Pension – a copy of your annual award letter and/or Bank Statement showing the direct deposit.
Workers’ Compensation and Unemployment – Award Letters with names and dates must be provided.
No Income – If you have no income, please provide a brief explanation of how you are being supported.
Alimony/ Child Support – a copy of your court-documented letter and/or Bank Statement showing the direct deposit.
We are accepting HCAP approval letters from hospitals .

2026 INCOME GUIDELINES
FAMILY SIZE	INCOME PER MONTH
1	$1,330.00
2	$1,803.00
3	$2,277.00
4	$2,750.00
5	$3,223.00
6	$3,697.00
7	$4,170.00
8	$4,643.00

Please note: If any portion of the application is incomplete or proof of income is not included, we will be unable to process your application.

If you have additional questions please call 800-962-1484 and a member of our Patient Services Department will be available to speak to you during business hours 8:00 am – 5:00 pm EST Monday – Friday. If you believe you are not eligible for financial assistance under the above program, Patient Services can discuss setting up payment arrangements with you at that time.

Patient Name*
Guarantor (if applicable)*
Email Address*
Phone Number*
Patient Mailing Address*
City, State and Zip Code*
Patient Date of Birth*
MM slash DD slash YYYY
Date of Transport/Service*
MM slash DD slash YYYY
Account Number*
Do you have health insurance?*
- Yes
- No
If yes, please provide the name of the insurance company:
Policy #
Group #:
Number of adults living in your household. (including yourself):*
Number of dependents living in your household.*
LIST TYPES OF INCOME FOR EACH ADULT MEMBER IN YOUR HOUSEHOLD
1st Member
Name:*
Relationship to Patient*
Income Source*
Monthly Income Amount*
Frequency*
2nd Member
Name:
Relationship to Patient
Income Source
Monthly Income Amount
Frequency
3rd Member
Name:
Relationship to Patient
Income Source
Monthly Income Amount
Frequency
If there is no income or no household member, please provide a brief explanation of how you are supported to meet your daily needs.
This document is legal and binding. Please include documents to support the income information you have provided. Your signature attests that, to your knowledge, the information provided is accurate.
Signature*
Date*
MM slash DD slash YYYY

LIST TYPES OF INCOME FOR EACH ADULT MEMBER IN YOUR HOUSEHOLD

1st Member

2nd Member

3rd Member