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 (example 24-E12345 or MDWI-23-12345) 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 *

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
Total Family Income	1	2	3	4+
$0 – $46,950	100%	100%	100%	100%
$46,951 – $55,200	80%	100%	100%	100%
$55,201 – $63,450	60%	100%	100%	100%
$63,451 – $71,700	40%	80%	100%	100%
$71,701 – $79,950	20%	60%	100%	100%
$79,951 – $88,200	0	40%	80%	100%
$88,201 – $96,450	0	20%	60%	100%
$96,451 – $104,700	0	0	40%	80%
$104,701 – $112,950	0	0	20%	60%
$112,951 – $121,200	0	0	0	40%
$121,201 – $129,450	0	0	0	20%
$129,451 +	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.

Please note: Approved hardship waivers are valid only for the year of transport. Ambulance trips that occur in upcoming years will require a new application.

STEP 1 - SIGNED STATEMENT. Write a statement describing your insurance or governmental assistance. For example: "I have no assistance or insurance to cover this ambulance bill."

STEP 2- PROOF OF TOTAL FAMILY ANNUAL INCOME = A SIGNED COPY OF YOUR MOST RECENT FEDERAL INCOME TAX FORM, including social security (line 20a).

Required Documents

1. Signed statement. Statement indicating your insurance or governmental assistance. For example: "I have no assistance or insurance to cover this ambulance bill."

2. Proof of total family income. A signed copy of your most recent federal income tax form, including social security (line 20a).

If you did not file taxes, submit proof of income or hardship 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.
- Copy of Student Financial Aide and/or Work-Study documents.
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, the claim must be submitted to health or accident insurance before a waiver can be approved. WHEN YOU RECEIVE A CHECK OR DENIAL, send us the payment and the explanation of benefits that you receivedNo

Please upload document*

Digital Signature *

If you have any questions about the waiver policy, call City of Madison Finance at (608) 266-4008.

If you have any questions about the application portal, please call (877) 618-0943.