Ems Transport Hardship Waiver Application Form - Anne Arundel County Fire Department
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1REQUEST FOR TRANSPORT FEE HARDSHIP WAIVER
A NEW HARDSHIP APPLICATION MUST BE SUBMITTED FOR EACH EMS TRANSPORT
Transported Patient Name: ______________________________________
Date of Birth ___/___/___
Home Address: ___________________________________________________________________________
__________________________________________________________________
Applicant Phone: ____________________________ Alternate Phone: _______________________________
Monthly Household Gross Income: ________________ Number of Dependents living in Household: _____
List of attached documentation:
W-2 withholding statements or unemployment check stubs for the past 90 days
Pay check stubs for the past 90 days for all persons employed in the home
Income tax return (most recent signed 1040 and/or W-2)
Application forms from Medicaid or other State-funded medical assistance program
Forms from employers or welfare agencies
Other (list): ____________________________________________________________________________
Responsible Party (if different from applicant)
Name: _____________________________________ Relationship to Patient: _________________________
Address (if different from applicant): _________________________________________________________
________________________________________________________________________________________
I do hereby request that I, as applicant or the party who is financially responsible for the applicant, be considered for a reduction in the
payment responsibilities as they relate to this EMS transport service fee. By signing this form I certify that I have no insurance that
can be billed for this charge. I declare that all of the information contained in this document and the attachments are true and accurate.
Further I understand that I may be held liable for any false statements pertaining to this waiver request. I hereby agree to notify the
Anne Arundel County Fire Department of any change in the financial status of the applicant or the responsible party that may affect
the ability to pay this EMS transport fee.
__________________________________________
___________________
Signature
Date
__________________________________________
Printed Name
For questions regarding the hardship waiver process, call 410-222-8367 or via e-mail to
Mail completed applications and supporting documents to:
Anne Arundel County Fire Department
Attn: EMS Billing Manager
8501 Veterans Highway, Millersville, MD 21108
Administrative Use Only
Incident # ______________________
Invoice # _____________________________
Date of Service: _________________
Date Received: ________________________
Waiver Disposition (circle)
Approved
Denied
Reason: _____________________________________
________________________________________________________________________________________________
Approval Signature________________________
Vendor Notified: ___________
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