Compassionate Care Program
Thank you for your interest in our Compassionate Care Program. Please refer to 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:
Proof of Income for entire household (at least one of the following):
Previous year tax return or letter of non-filing from the IRS (1-800-908-9946) (only relevant
pages, e.g., 1040 Form that includes income and dependents)
Hospital Charity Approval Letter (if applicable)
Award letter from local Department of Human Services (DHS) or Department of Family
Services (DFS)
Paycheck stubs (if employed) or bank statements from the previous two (2) months for the
entire household
A letter from your local employment office indicating no wages/benefits (if unemployed or
retired) are currently being received, or proof of any other sources of income or aid (i.e. SSI,
SSA, SSDI, Unemployment, etc.)
Your quarterly profit and loss statement (if self-employed)
Please forward the completed application with all required documentation within 10 business days to:
American Medical Response
Attention: Patient Advocates
4701 Stoddard Rd.
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 Customer
Care 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 understand that all
decisions are final.
• I certify that there is not any liability or third-party coverage pertaining to all transports related to this application.
Signature Date
