I, _____________________ am requesting assistance with the transportation bill for (name) ________________________, date of transportation _______________, account number ________________ for the amount of $___________.

I understand that this application is made so that the ambulance service can determine my eligibility for uncompensated services based on the established criteria on file at the ambulance service. If any information I have given proves to be untrue, I understand that the ambulance service may re-evaluate my financial status and take whatever action is deemed to be appropriate.

I certify that the current information given is true and accurate to the best of my knowledge. Further, I will make application for any assistance (Medicare, Medical Assistance, etc.) which may be available for payment of my ambulance service charges and I will assign or pay to the ambulance service the amount recovered toward the ambulance service charges.

Current Information:

Medicaid Recipient currently: ___yes ___no

(If yes please send copy of card)

Medicaid Recipient within year: ___yes ___no

QMB Medicaid Recipient: ___yes ___no

Deceased Patient, No estate: ___yes ___no

Number of Dependents in your Household _____________

Income: Monthly $_____________ Yearly $ _____________

Total Basic Monthly Expenses as detailed below. $ __________

Maximum payment you feel you could make $ _____________

Do you own your home? __Yes __No If yes, approximate value:_______

Do you own a car? __Yes __No

Do you have savings? ___

Attach copies of past two pay stubs or show proof of income along with proof of your Basic Monthly Expenses (utility bills, rent, or routine medications) you would like us to consider to determine eligibility.

Signature of applicant: ____________________________

Relationship to patient: ___________________________