Compassionate Care Program
Thank you for your interest in our Compassionate Care Program. Please reference the list below for information
required to process your application. We will not be able to process your application if it is returned incomplete, or
the required documentation is not provided. *Please note that additional documentation not initially requested
below may be required following review of your situation.
All Applicants:
The previous year’s tax return or letter of non-filing from the IRS (1-800-908-9946).
Hospital Charity Approval Letter (if applicable)
AND
Employed Applicants:
Paycheck stubs or bank statements from the previous three (3) months for the entire household.
Unemployed / Retired Applicants:
A letter from your local employment office indicating no wages/benefits are currently being received, or
proof of any other sources of income or aid (i.e. SSI, SSA, SSDI, Unemployment, etc.)
Self Employed Applicants:
Your quarterly profit and loss statement.
College Students Over 18 Years of Age:
Documentation showing current enrollment is required (i.e. student loan documentation, a current class
schedule, school account summary, etc.).
If claimed as a dependent, the legal guardian’s previous tax filing, along with paycheck stubs and bank
statements from the previous three (3) months.
Non-US Residents:
Proof of residence (passport, visa, check stubs, bank statement, etc.).
Please forward the completed application with all required documentation within 10 business days to:
American Medical Response
Attention: Patient Advocates
4701 Stoddard Dr.
Modesto, CA 95356
Your application for the Compassionate Care program will be thoroughly reviewed, and a letter will be mailed to you
informing you of our determination. If you have any questions, please contact our Customer Service Department at
1-800-913-9106.
COMPASSIONATE CARE APPLICATION
CONTACT INFORMATION
Patient Name:
Account #:
Responsible Party:
Account Balance:
Address:
LOB:
Home Phone #:
Cell Phone #:
Employer Name:
HOUSEHOLD SIZE: ________ (Include yourself, spouse and dependents only)
Name
Relationship to Patient
Age
(List additional household members on a separate sheet)
MONTHLY HOUSEHOLD INCOME
Net Wages $__________
SSI, SSA, or SDI $__________
Unemployment $__________
Pension $__________
Cash/Food Assistance $__________
Other Income Source: ______________________ $__________
Total $__________
MONTHLY MEDICAL EXPENSES
Description
Health Insurance Premiums/COBRA ______________________ $__________
Pharmacy ______________________ $__________
Doctor Payments ______________________ $__________
Hospital Payments ______________________ $__________
Dental Payments ______________________ $__________
Specialist Payments ______________________ $__________
Other Medical Expense ______________________ $__________
Total $__________
• I declare that above information is a true and accurate representation of my financial status.
• I understand that American Medical Response is required by law to keep any information I provide confidential.
• I understand that if I do not qualify for a reduction or waiver of charges by the terms of this program, I will remain
personally liable for the charges of the services rendered by American Medical Response.
• I certify that there is not any liability or third party coverage pertaining to all transports related to this application.
Signature Date
