Hardship Waiver Information Patient Information Hardship Waiver Information Portal for City of Madison Ambulance Transports Please provide patient information Run Number * Enter the number exactly as it shown on the invoice, with any hyphens or colons Date of Service * Your run number and date of service can be found on your invoice. Patient Information First Name * Last Name * Your Email * Address 1 * Address 2 City * State * Zip Code * Primary Phone Number * Next Hardship Waiver Information The City of Madison Hardship Waiver is designed to help people who have no insurance or the means to pay. Failure to completely and accurately provide the information required below may result in denial of the waiver. The schedule below provides the percent of fee waived based on total family income and number of individuals in household. Total Family Income Number of People in Household 1 2 3 4+ $0 – $45,180 100% 100% 100% 100% $45,181 – $53,250 80% 100% 100% 100% $53,251 – $61,320 60% 100% 100% 100% $61,321 – $69,390 40% 80% 100% 100% $69,391 – $77,460 20% 60% 100% 100% $77,461 – $85,530 0 40% 80% 100% $85,531 – $93,600 0 20% 60% 100% $93,601 – $101,670 0 0 40% 80% $101,671 – $109,740 0 0 20% 60% $109,741 – $117,810 0 0 0 40% $117,811 – $125,880 0 0 0 20% $125,881 + 0 0 0 0 Hardship Waiver Requirements If you would like to be considered for a waiver all four of the following steps must be completed and submitted to our office via on-line or by mailing documents to PO Box 457, Wheeling, iL 60090: STEP 1 - SIGNED STATEMENT. You must include a signed statement indicating your insurance or governmental assistance. For example: "I have no assistance or insurance to cover this ambulance bill." Please upload document * STEP 2- PROOF OF TOTAL FAMILY ANNUAL INCOME = A SIGNED COPY OF YOUR MOST RECENT FEDERAL INCOME TAX FORM, including social security (line 20a). If you did not file taxes, proof of income/hardship from an independent third party must be submitted, such as: A photocopy of your most recent signed Homestead Schedule H A photocopy of a Statement of Benefits from either Food Share, SSI, Disability, or Unemployment Copy of Hospital Charity Care Approval for the same date of service. Please upload document * STEP 3 - ARE YOU RECEIVING OR ELIGIBLE FOR GOVERNMENTAL ASSISTANCE such as medical assistance, Medicare, SSI or general assistance? Yes. If yes, you must send us an explanation of benefits and payments you receive before the waiver appliesNo Please upload document STEP 4 - DO YOU HAVE PRIVATE HEALTH OR ACCIDENT INSURANCE? Yes. If yes, it must be applied for before being considered for a waiver. WHEN YOU RECEIVE A CHECK OR DENIAL, send us the payment and the explanation of benefits that you receivedNo Please upload document Digital Signature * BackNextSubmit Your Data Back
