North Jefferson County Ambulance District

Dedication, Compassion, Teamwork!

Patient Resources

To obtain a printable PDF copy of our forms, please click the document name below:

Notice of Privacy Practices

Crime Victims Form


Financial Assistance

North Jefferson County Ambulance District offers financial assistance to make healthcare affordable and accessible to all members of the community. We also provide discounted and charity care for eligible individuals. If payment of your healthcare expenses could create a financial hardship for you, our Patient Accounts staff will work with you to apply for financial assistance.

Information you provide is confidential and is only reviewed by staff processing your application.


Eligibility

Eligibility for financial assistance is based on:

  • Household income, in relation to federal poverty guidelines
  • Any additional financial hardship
  • Medically necessary care
  • The account must be a current, non-collection-referred account


How to Apply for Financial Assistance

To apply please complete an application for financial assistance. Along with the application, you must submit all of the following documents;

  • Copies of most current Federal Income Tax Return for each household member(s).
  • Copies of most current W-2’s for each household member(s).
  • Copies of the three most recent, paycheck stubs or a statement of earnings from the employer for each household member.


Please provide the following documents if applicable;

  • Copies of unemployment and/or disability compensation statements for each household member.
  • Copies of social security or pension benefits income for each household member.
  • Copies of government assistance notices, such as Social Security Disability and Medicaid Programs for each household member.

All of these materials must be submitted with your application. Incomplete applications will not be processed and returned to you. We can help you prepare, complete, and submit your application.

Notification

It generally takes 30 days to process applications. You will be notified in writing with a letter sent by US Mail as to whether your application was approved or denied.  Approvals for financial assistance are valid for one calendar year and must be renewed each year.  For more information, contact Patient Accounts (636) 677-3399.