Financial Assistance Program Application Process

Area Ambulance Service is a not-for profit organization that provides emergency and nonemergency transportation. As part of our commitment to provide charitable services to patients in our community, a Financial Assistance Program has been developed. This program provides discounts on transportation charges for patients that meet predetermined household income and family size requirements. Discounts range from 10 to 100 percent based on applicant eligibility. If you are under 21 years of age and a full time student, this application needs to be completed by your family. Applicants must complete the application and provide the required documentation to be considered for a discount. If the application is incomplete or returned without the proper documentation, the application will be denied.
The following documentation should be included with your application:

• Bank statements for the past 2 months
• Pay stubs for the last 3 pay periods
• W2 forms for the most recent tax year
• Federal tax forms for the most recent year, if filed
• Self-employed applicants should submit tax forms for the past 3 years
• Pension benefits
• Unemployment benefits
• Social Security or Social Security Disability benefits
• If unemployed and have not worked in the past year, please provide a letter clearly documenting you support yourself.

If you prefer to submit this form via US mail please return your completed application along with the required documentation to the following: Area Ambulance Service, PO Box 362, Cedar Rapids, Iowa, 52406. For assistance with questions, please contact our billing department at 1-800-979-1636.

I understand that this application is made so Area Ambulance Service can determine my eligibility for uncompensated services based on the financial information provided with this application. I have no other insurance or assistance to file a claim on the balance due. If any information I have given proves to be untrue, I understand that the ambulance service may re-evaluate my financial status and take whatever action is deemed appropriate.

I certify that all the information given is true and accurate. Further, I will make application for any assistance, including Medicare, Medicaid, etc., which may be available for payment of my ambulance service charges. I will assign insurance benefits to Area Ambulance Service and pay Area Ambulance Service any amount recovered toward the ambulance bill. I understand the information submitted is subject to verification by Area Ambulance Service and subject to review by other agencies as required for verification purposes.