Charity Care / Financial Hardship Application

Instructions for Applicants ProMed Ambulance Company is committed to ensuring patients have access to medically necessary ambulance services, regardless of financial means. If you are experiencing financial hardship, you may qualify for a Charity Care discount based on your household income compared to the Federal Poverty Level (FPL Please complete all sections of this form. Attach proof of income (most recent tax return, W-2, or 2 consecutive pay stubs for all household members Return the completed form and documentation to ProMed within 30 days of the date on your statement. Incomplete applications cannot be processed.