(A) In the event any person claims they are unable to pay for any services rendered by the emergency medical service due to financial hardship, the Fire Chief, or his or her designee, shall assist the party in determining whether the person utilizing the service is qualified for Medicare and/or Medicaid assistance. If the party is not qualified for government assistance, the Fire Chief, or his or her designee, shall assist the party in applying for financial hardship relief through the City of Union City.
(B) Persons or parties requesting relief of debt from the emergency medical service shall complete the Union City Fire Department Financial Evaluation Form in its entirety and include:
(1) Copy of the most current Federal tax forms with all schedules, including W-2’s;
(2) Copy of the most recent three paycheck stubs;
(3) Copy of the most recent three bank statements for each account;
(4) List of outstanding medical debts and monthly pharmacy costs;
(5) Name and telephone number of Medicaid caseworker, if applicable;
(6) Copy of the applicant or guardian’s drivers license.
(C) Persons or parties must return all information to the Fire Chief, or his or her designee, for evaluation within ten business days to be considered for relief. All applications for financial hardship debt relief shall be reviewed by the Board of Public Works and Safety for evaluation and final decision in the forgiveness of the debt to the emergency medical service.
(Ord. 2008-15, passed 12-8-08; Am. Ord. 2011-07, passed 9-26-11)