North Central EMS Financial Assistance Policies & Procedures North Central EMS: This is a Charity Care Program for those patients who whose income falls below the federal poverty guidelines and is generally unable to pay for transportation services provided. Patients meeting the income requirements for their household size will qualify for a 20% discount for all transportation services. Proof of income is determined by 1) check stubs, 2) a recent income tax return or W-2. 3) a signed statement from the patient or account guarantor stating their income or how they are supported. 4) acceptance into an income-based government assistance program. Financial Services will determine eligibility for a charity write-off using the following income guidelines for 2020:

Person(s) in family/household Maximum Income

1) $38,280

2) $51,720

3) $65,160

4) $78,600

5) $92,040

6) $105,480

7) $118,920

8) $132,360

A. Upon review of the requestor’s proof of income documentation, North Central EMS billing department will mail a Financial Assistance Approval form to the mailing address provided. This form will note whether a 20% discount has been approved. B. The North Central EMS billing department will scan all appropriate documents into the patient’s chart for the transport for that Guarantor’s record including proof of income, copies of applications or copies of insurance cards. C. These files will be retained for a minimum period of seven years for audit purposes. D. Patients approved for the North Central EMS Financial Assistance are required to submit a new application for each date of service. E. For the purpose of income determination, income from seasonal employment will be adjusted to reflect a yearly wage. F. North Central EMS reserves the right to revoke and/or reverse financial assistance approval to patients based on assets, income or non-taxable income (i.e. S.S., Pensions, Dividends, IRA / 401k withdraws, etc.,) that were not previously reported. The North Central EMS Charity Program is for those individuals and families that have no ability to pay. G. Our billing procedure (after insurance payments and/or self-pay) provides three statements to the patient. The first statement includes a 10% discounted amount as prompt payment in full. The second and third statements simply state the full balance due. If the patient ignores or does not respond to this notification, regardless of payments being made, the account then goes into a collection status. It is the patient’s responsibility to contact the Financial Services office to set-up reasonable payment plans if they cannot pay in full within those four stmts. It is also the responsibility of the patient to complete a charity app if they believe their annual income for their family size may qualify them for possible assistance.