§ 34.48 EMS FEES.

   (A)   The fees for county EMS services shall be as follows:

 

Ambulance mileage	A0425	$16
ALS-1 non-emergency	A0246	$800
ALS-1 emergency	A0427	$1,100
BLS non-emergency	A0428	$600
BLS emergency	A0429	$750
ALS-2 emergency	A0433	$1,300
Specialty care transport	A0434	$1,800

 

   (B)   The application for a hardship exemption from EMS fees shall be as follows:

   Ambulance Hardship Application

 

It is the policy of your ambulance provider to require payment for services in a timely manner. In limited cases, a hardship exemption may apply, when properly documented and verified. In order to request a hardship exemption, you must provide the information listed below and return this form within ten business days. Failure to provide sufficient information and documents to determine hardship eligibility will result in denial of your application. You must sign this form, authorizing verification of the information provided. After review of the information, your ambulance provider will determine your eligibility for a hardship exemption, which may include monthly payments and/or an adjustment to your account. If vou have received an insurance payment for ambulance services, you are not eligible for a hardship exemption until you have paid the full amount received from the insurance. THIS IS AN ATTEMPT TO COLLECT A DEBT AND ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE

 

_______________________________         _______________________

Patient Name                      Date of Service

Ambulance Service Provider Call Number

(1)   Are you employed?       YES    NO       Full Time:         YES    NO

_______________________________         _______________________________

   Name of Employer                                                 City          State    Zip

(2)   Are you disabled and unable to work?      YES    NO

(3)   Are you retired and on a fixed income?    YES    NO

(4)   Monthly NET household income:    $       

(5)   Number of adults in household:     ___________

(6)   Number of dependents under age 18 in household:       

(7)   Have you received insurance payments for your ambulance charges?       YES    NO

(8)   Providing the following information will help in determining your eligibility for a hardship exemption:

•   Copies of pay check stubs or unemployment check stubs for the past 30 days.

•   Copies of most recent W-2 withholding statements.

•   Copy of most recent income tax return, state or federal.

•   Any information that would show welfare or state-funded assistance programs.

•   Documentation of any catastrophic situations.

•   Documentation of outstanding debts.

I certify that the information provided is accurate. I authorize verification by the ambulance provider or authorized billing agency:

_______________________________         _______________________________

Patient Signature                   Date

RETURN COMPLETED FORM AND DOCUMENTS TO:

Ambulance Billing Services, Inc.

P.O. Box 727

Elkhart, IN 46515-0727

QUESTIONS? Call 1-877-293-3535 or [phone]

FAX: [phone]

Attestation Statement

Attention: Wisconsin Physicians Service

Medicare Provider Enrollment

This letter is to attest that Switzerland County Auditor will be legally and financially responsible in the event that there is any outstanding debt owed to CMS.

________________________________________________________________________________

Printed Name and Title

________________________________________________________________________________

Signature and Date

(Res. 05-04-2016-1, passed 5-2-2016)