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
Medicount maintains physical, electronic and procedural safeguards to guard your nonpublic personal information. Our operational and data processing systems are contained in a secure environment and that environment is access-controlled. To secure sensitive communications between your computer and our web servers, we have implemented digital certificates and enabled strong, RSA1024-bit, encryption. We use secure sockets layer, SSL, security protocol to protect all exchanges of information via our web pages that are considered private or confidential.
