EHS GROUND AMBULANCE
Ambulance Fee Assistance Program Form
Please use the form below to appeal the fee levied on care received from the EHS
Ground Ambulance system.
Tell Us About You
Name: Agency/Facility:
Address: City & Province:
Postal Code: Phone (Home): Phone (Work):
Are you a: ❑Patient ❑Relative ❑Friend ❑Other (please specify)
Please supply as many details as possible in the following fields. Any information you can
provide increases our ability to appropriately review and respond to your appeal.
Patient Patient
Name: Phone #:
Civic Date of Occurrence:
Location: (dd/mm/yy)
Invoice #: Municipality/
Community:
Return Completed Forms To: For Office Use Only. Do Not Write In This Area.
EHS Ground Ambulance Operations
Attn: Manager of Billing File #
239 Brownlow Ave., Suite 300
Dartmouth, NS B3B 2B2 Date Rec’d: Date F’wd
[email protected]
Telephone: (902) 832-8337 Date Processed:
or toll-free 1-888-280-8884
Fax: (902) 832-2954
Ambulance Fee Assistance Program
Please complete the following checklist. This information will be used to help determine your eligibility to
have your service fee waived under the financial hardship category. In order to allow EHS to verify your
financial situation, it is also necessary to submit your household’s “Notice of Assessment” forms from the
Canada Revenue Agency for the most recent tax year. Eligibility is determined based on the criteria below
as well as the household’s assessed income and family unit size. Application must be received by the billing
office within 90 days from the date the invoice was issued. For full details, please consult the EHS Service
Fee Appeals website at http://novascotia.ca/dhw/ehs/ambulance-fees.asp or contact EHS as outlined above.
EHS GROUND AMBULANCE
Ambulance Fee Assistance Program Form
1. Demographics: Patient Age Age:
Gender ❑Male ❑Female
2. Are you 19 years old or older? ❑Yes ❑No
(*note – patients who were under the age of 19 and resided
with their parent(s)/guardian(s) at the time of the invoice
must have their parent(s)/guardian(s) appeal on their behalf).
3. Do you have more than one Ground Ambulance service fee ❑Yes ❑No
outstanding?
4. Are you married (includes living common-law)? ❑Yes ❑No
5. How many dependents do you have? ❑0 ❑1 ❑2 ❑3 ❑4
A child of the patient or the patient’s spouse, who is: ❑5 ❑6 ❑7 ❑8 ❑9
1. Financially dependent on either, and is under 19, or ❑10 or more
2. under 25 and enrolled full-time in an education institution,
or
3. over 18 and disabled.
6. Are you a recipient of Employment Support and/or Income ❑Yes ❑No
Assistance through the Nova Scotia Department of
Community Services?
7. To your knowledge, are you eligible for any ❑Yes ❑No
Federal/Provincial Government Programs that cover the cost
of Ground Ambulance transportation?
8. Do you have third party insurance that would cover the cost ❑Yes ❑No
of the Ground Ambulance transportation?
For purposes of verifying my financial situation:
❑ 1. I am including the “Notice of Assessments” for my household, received from the
Canadian Revenue Agency
I certify that the information I have provided on behalf of the patient/or for my eligibility is
correct. I also give permission to allow the Nova Scotia Department of Health and Wellness
or agents acting on its behalf to review my financial information for the purposes of
determining if I am eligible to have my service fee from the EHS Ground Ambulance system
waived on the basis of financial hardship.
Signature:
