Get Ca Request For Ems Billing Low Income Assistance Form - City Of Los Angeles 2021

This guide provides clear instructions on completing the CA Request For EMS Billing Low Income Assistance Form for low-income individuals seeking assistance with ambulance billing in Los Angeles. By following these steps, you can ensure that your application is completed accurately and submitted on time.

Follow the steps to fill out the form online.

1. Click ‘Get Form’ button to obtain the CA Request For EMS Billing Low Income Assistance Form and open it in your editor.
2. Fill in your full name, including your first, middle, and last name in the designated field. Ensure that the name matches official identification.
3. Enter the date of service when you were transported by ambulance. This information is crucial for processing your request.
4. Provide your account number, which is typically located on the billing statement you received.
5. Complete the street address section, including any apartment number, and ensure that your city, state, and ZIP code are accurate.
6. Input your daytime phone number and, if applicable, an alternative phone number. This allows the reviewing department to contact you if needed.
7. Optionally, provide your email address for further communication regarding your application.
8. Review the qualifications section carefully. Check if you are currently enrolled in a qualifying low-income program or if your household income falls below the specified limits.
9. If applicable, indicate your current enrollment in a qualifying program by selecting the appropriate option and including supporting documentation, such as your most recent LADWP bill or DPSS award letter.
10. If applying based on income, provide household information, including the total number of adults and children in your household. Attach all required documentation to prove your income, including tax returns and financial support documents.
11. Sign and date the form in the designated area, confirming that all information provided is accurate and complete.
12. Once all sections are completed, save your changes. If necessary, download or print the form to retain a copy for your records.
13. Submit your completed form and documentation via mail to the Los Angeles City Fire Department Ambulance Billing at the address specified in the form.

Get started on your application and submit the required documents online today!