2007/02/28 Council Agenda Packet

q Section 3: 1. An application form (Appendix 5) must be completed in full and submitted to the City of Everett's third party billing company. Application forms may be obtained from either the third party billing company or the Everett Fire Department. 2. Requests for financial assistance may be initiated by sources such as a physician, community or religious groups, social services, hospital personnel, the patient, guarantor, or family member. 3. Individuals who are unable to complete the application for financial assistance themselves and lack the social network/family necessary to help them complete the necessary paperwork will be considered on a case-by-case basis. 4. The third party billing company will log and forward all requests with documentation and a recommendation regarding eligibility to the EMS division of the Everett Fire Department. 5. The Fire Chief and the City Treasurer (or designees) will review all requests and base their decision of eligibility based on the data gathered via the third party billing company, along with its recommendation. 6. The City of Everett's determination of eligibility will be indicated in writing on the application form with signatures from both the Fire Chief and the City Treasurer (or designees), and returned to the third party billing company. 7. The third party billing company will communicate the determination to the patient or the patient's authorized representative and make any necessary adjustments to the patient's account. 8. The third party billing company will provide the EMS Division of the Everett Fire Department with monthly reports of all adjustments made to patient accounts. 9. The EMS Division of the Everett Fire Department will audit the adjustment reports to assure that the proper adjustments were made. Councilmember Introducing Resolution PASSED AND APPROVED THIS DAY OF , 2007 Council President 13 � 2