DC FIRE AND EMS DEPARTMENT HARDSHIP DETERMINATION

RETURN MAIL TO: Account Number: ________________________

DC Fire and EMS Department Patient Name: ________________________
P.O. Box 27767
Washington, DC 20038
Notice Date: ________________________
Thank you for submitting a hardship assistance request to the Fire and EMS Department. Based on a review
of this case, our billing office has made the following determination:

The amount owed has been reduced and may qualify for delayed payment terms. Please provide
payment according to the terms checked below:

The amount owed qualifies for complete reduction. No payment is required.

The amount owed is reduced to $_______________. Please mail check payment made out to DC
Treasurer no later than ninety (90) calendar days from the date of this notice.

Please SIGN and RETURN this form if this box is checked.

Based on criteria used by our department, the patient does NOT qualify for hardship eligibility
because of the following reason(s):

The patient does not meet hardship income or unemployment qualification requirements.

The patient is covered by healthcare or other insurance that may pay the outstanding balance.

The patient qualifies for Medicaid or may qualify for Medicaid coverage during the next year.

The patient received direct payment from insurance but did not pay the ambulance charges owed.

Other reason:

By signing this form, I am entering into an agreement with the Government of the District of Columbia for
reducing the ambulance charges owed by me according to the terms listed above. I recognize that I am
responsible for making payment. I agree to abide by the terms indicated above and make payment
promptly. By signing this form I certify, under applicable penalties of law, that I am the patient requesting
hardship assistance or I am authorized by law or agreement to sign on the patients behalf.
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