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14 <br /> EMS FINANCIAL ASSISTANCE POLICY <br /> 3.0 Eligibility Criteria/Financial Assistance Schedule <br /> 3.1 Full debt forgiveness will be provided to a patient with a gross family <br /> income at or below 100% of current published Federal Poverty Income <br /> Guidelines. <br /> 3.2 Partial debt forgiveness will be awarded according to the schedule in <br /> Appendix 6.1. The resulting responsibility may be adjusted by joint <br /> approval of the Emergency Medical Services (EMS) Division Chief and <br /> City Treasurer(or designees), based on extraordinary nondiscretionary <br /> expenses relative to the amount of the responsible party's medical care <br /> expenses or limitations on the responsible party's future income earning <br /> capacity due to illness. <br /> 4.e Financial Assistance Procedures <br /> 4.1 An application form (Appendix 6.2) must be completed in full and <br /> submitted to the City of Everett's third party billing company. Application <br /> forms may be obtained from either the third party billing company or the <br /> Everett Fire Department. <br /> 4.2 Requests for financial assistance may be initiated by sources such as a <br /> physician, community or religious groups, social services, hospital <br /> personnel, the patient, guarantor, or family member. <br /> 4.3 Individuals who are unable to complete the application for financial <br /> assistance themselves and lack the social network/family necessary to <br /> help them complete the necessary paperwork will be considered on a <br /> case-by-case basis. <br /> 4.4 The third party billing company will log and forward all requests with <br /> documentation and a recommendation regarding eligibility to the EMS <br /> division of the Everett Fire Department. <br /> 4.5 The EMS Division Chief and the City Treasurer (or designees) will review <br /> all requests and base their decision of eligibility based on the data <br /> gathered via the third party billing company, along with its <br /> recommendation. <br /> 4.6 The City of Everett's determination of eligibility will be indicated in writing <br /> on the application form with signatures from both the EMS Division Chief <br /> and the City Treasurer (or designees), and returned to the third party <br /> billing company. <br /> 4.7 The third party billing company will communicate the determination to the <br /> patient or the patient's authorized representative and make any necessary <br /> adjustments to the patient's account. <br /> 2 128 <br />