Madison Hardship Form

Madison Hardship Application
Enter the number exactly as it shown (example 24-E12345, MDWI-23-12345, CMA26-000000:1) on the invoice, with any hyphens or colons.

Your run number and date of service can be found on your invoice.
Account / Run #*
Below are examples of format
Patient's Date of Birth*

MonthDayYear
Patient's Name*

First NameLast NameSuffix
Date of Service*

MonthDayYear
Patient Address*

Street Address / PO Box

Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
- Hardship Waiver Information
  The City of Madison Hardship Waiver is designed to help people who have no insurance or the means to pay. Failure to completely and accurately provide the information required below may result in denial of the waiver.
  
  The schedule below provides the percent of fee waived based on total family income and number of individuals in household.
- Hardship Waiver Requirements
  If you would like to be considered for a waiver all four of the following steps must be completed and submitted to our office via on-line or by mailing documents to PO Box 501368, Indianapolis, IN 46250.
  
  Please note: Approved hardship waivers are valid only for the year of transport. Ambulance trips that occur in upcoming years will require a new application.
  
  STEP 1 - SIGNED STATEMENT. Write a statement describing your insurance or governmental assistance. For example: "I have no assistance or insurance to cover this ambulance bill."
- Write a statement here
- STEP 2- PROOF OF TOTAL FAMILY ANNUAL INCOME = A SIGNED COPY OF YOUR MOST RECENT FEDERAL INCOME TAX FORM, including social security (line 20a).
  
  Required Documents
  
  1. Signed statement. Statement indicating your insurance or governmental assistance. For example: "I have no assistance or insurance to cover this ambulance bill."
  
  2. Proof of total family income. A signed copy of your most recent federal income tax form, including social security (line 20a).
  
  If you did not file taxes, submit proof of income or hardship such as:
  
  A photocopy of your most recent signed Homestead Schedule H.
  A photocopy of a Statement of Benefits from either Food Share, SSI, Disability, or Unemployment.
  Copy of Hospital Charity Care Approval for the same date of service.
  Copy of Student Financial Aide and/or Work-Study documents.
  Please upload document *
- Document
  
  pdf, jpg, jpeg, png, gif
  Cancelof
- Full Name*
- Yes. If yes, you must send us an explanation of benefits and payments you receive before the waiver appliesNo
- Yes. If yes, the claim must be submitted to health or accident insurance before a waiver can be approved. WHEN YOU RECEIVE A CHECK OR DENIAL, send us the payment and the explanation of benefits that you receivedNo
- Signature*
  
  Clear
- Please verify that you are human*
- If you have any questions about the waiver policy, call City of Madison Finance at (608) 266-4008.
  
  If you have any questions about the application portal, please call (888) 849-6628
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Madison Hardship Application