Ambulance RATES

• 2013 City of Madison Ambulance Rates
• 2012 City of Madison Ambulance Rates
• 2011 City of Madison Ambulance Rates
• 2010 City of Madison Ambulance Rates
• 2009 City of Madison Ambulance Rates
• 2006 - 2008 City of Madison Ambulance Rates
• 2005 City of Madison Ambulance Rates
• 2004 City of Madison Ambulance Rates

AMBULANCE BILLING

Beginning 1/1/2013, the City of Madison utilizes billing services from Intermedix. For more information, please visit:

• Ambulance Billing, Fire Department, EMS

Ambulance Hardship Waiver Information

The City of Madison Hardship Waiver (PDF) 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.

Total Family Income	Number of People in Household
	1	2	3	4
$0 - $28,350	100%	100%	100%	100%
$28,351 - $30,375	80%	100%	100%	100%
$30,376 - $32,400	60%	100%	100%	100%
$32,401 - $34,425	40%	80%	100%	100%
$34,426 - $36,450	20%	60%	100%	100%
$36,451 - $38,450	0	40%	80%	100%
$38,451 - $40,450	0	20%	60%	100%
$40,451 - $42,075	0	0	40%	80%
$42,076 - $43,700	0	0	20%	60%
$43,701 - $45,325	0	0	0	40%
$45,326 - $46,950	0	0	0	20%
$46,951+	0	0	0	0

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:

STEP 1: SIGNED STATEMENT
You must include a signed statement indicating your insurance or governmental assistance. For example: "I have no assistance or insurance to cover this ambulance bill."

STEP 2: PROOF OF TOTAL FAMILY ANNUAL INCOME
We will need A SIGNED COPY OF YOUR MOST RECENT FEDERAL INCOME TAX FORM, including social security (line 20a).

If you did not file taxes, proof of income/hardship from an independent third party must be submitted, 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

STEP 3: ARE YOU RECEIVING OR ELIGIBLE FOR GOVERNMENTAL ASSISTANCE
such as medical assistance, Medicare, SSI or general assistance?

• YES: If yes, you must send us an explanation of benefits and payments you receive before the waiver applies.
• NO

STEP 4: DO YOU HAVE PRIVATE HEALTH OR ACCIDENT INSURANCE?

• YES: If yes, it must be applied for before being considered for a waiver. WHEN YOU RECEIVE A CHECK OR DENIAL, send us the payment and the explanation of benefits that you received.
• NO