DC FIRE AND EMS DEPARTMENT HARDSHIP REQUEST

RETURN MAIL TO:

DC Fire and EMS Department Account Number: ________________________

P.O. Box 27767
Washington, DC 20038 Date of Service: ________________________

Thank you for submitting a hardship assistance request to the Fire and EMS Department. When submitting a
hardship request, our Department requires that the patient or a party representing the patient accurately
provide all the following information.

_______________________________ _________________________ ____________________

Name of Patient Last 4 Numbers of Patient SSN Patient Birth Date

_____________________________________ _____________________ _____ _____________

Patient Mailing Address Apt # City State Zip Code

_______________________ ______________________________ _________________________

Patient Contact Telephone Patient Representative (If Applicable) Representative Contact Number

Please answer all of the following questions:

YES NO Is the patient unemployed with an annual income of less than $16,335 or is the patient
unemployed and receiving unemployment benefits?

YES NO Is the patient considered permanently disabled for tax reporting purposes?

YES NO Does the patient receive any form of Federal or District of Columbia income assistance
based on Federal Poverty Level Guidelines?
When transported, did the patient have healthcare insurance or could the patient qualify
YES NO for healthcare insurance coverage (such as Medicaid) within the next year?

YES NO Did the patients insurance deny paying ambulance charges in full or in part?

By signing this form, I am requesting the Government of the District of Columbia consider reducing the
amount of my ambulance charges for reasons of financial hardship. I understand that I may be required to
provide documentation supporting this request, if asked. By signing this form I certify, under applicable
penalties of law, that all of the above is accurate to the best of my knowledge and that I am not
misrepresenting any of the information provided. Billing Office Date
Stamp Received:

_____________________________________________ _____________________
Signature of Patient or Patient Representative Date

Fax Number: 1-614-987-2075 https://billpay.intermedix.org/billpay

Billing Questions? Please Call 1-888-828-8019