Get Return Completed Forms To Ambulance Fee

Filling out the Return Completed Forms To Ambulance Fee is an important step to appeal the charges for services received from the EHS Ground Ambulance system. This guide will provide a clear, step-by-step process to help you complete the form easily and accurately.

Follow the steps to successfully complete your appeal for ambulance fee assistance.

1. Click 'Get Form' button to obtain the form and open it for completion.
2. In the 'Tell Us About You' section, provide your name, agency or facility name, address, city and province, postal code, and phone numbers for both home and work.
3. Indicate your relationship to the patient by selecting one of the options: patient, relative, friend, or other. If you select 'other', please specify your relationship.
4. In the 'Patient' section, provide the patient's name, civic location, invoice number, patient phone number, date of occurrence (in dd/mm/yy format), and the municipality or community.
5. In the 'Ambulance Fee Assistance Program' section, complete the demographics questions, including patient age and gender, and indicate if the patient is over 19 years old.
6. Answer the eligibility questions regarding outstanding ambulance service fees, marital status, number of dependents, and if you receive any government assistance.
7. Confirm if you know your eligibility for any Federal or Provincial programs that cover the cost of Ground Ambulance transportation.
8. Indicate any third-party insurance coverage that would apply to the ambulance costs.
9. For financial verification, check the box that affirms inclusion of your 'Notice of Assessment' from the Canada Revenue Agency.
10. Finally, provide your signature to certify that all the information is accurate and grant permission for financial information review.
11. Once you have filled out all necessary sections, review the form for accuracy, save changes, and follow the appropriate steps to download, print, or share as needed.

Submit your completed forms online to ensure a smooth appeal process.