Timbrook Public Safety Center Telephone: (540) 662-2298
231 East Piccadilly Street, Ste. 330 FAX: (540) 542-1318
Winchester, VA 22601 Website: www.winchesterva.gov
WINCHESTER FIRE AND RESCUE
EMS TRANSPORT FEE WAIVER FORM
Transport Fee Waiver Form must be submitted for each transport
PATI
ENT NAME: ______________________________________________________________________
ADD
RESS: ____________________________________________________________________________
NAME IF NOT THE PATIENT: __________________________________________________________
MON
THLY HOUSEHOLD GROSS INCOME: $_____________________________________
HOU
SEHOLD SIZE (# of People): ____________
I am applying to City of Winchester Fire and Rescue Department for a waiver of payment for my EMS
transport fee.
[ ] I c
ertify that I have no insurance that can be billed for this charge, and I am unable to pay for this
service.
[ ] I certify that I do have insurance that was billed for this charge with charges being applied to my
deductible and I am unable to pay the remaining balance due.
[ ] I certify that I do have insurance that was billed for this charge with payment being made, leaving a
copay and I am unable to pay the remaining balance due.
I ce
rtify above information is true and accurate to the best of my knowledge, and that I will be held
responsible for any false statements made herein. I acknowledge that additional documentation may be
requested.
__________
__________________________________ ___________________________
Signature Date
If you
have any questions please call (540) 662-2298. Please hand deliver or mail completed form to:
Win
chester Fire & Rescue Department
231 E Piccadilly St, Suite 330
Winchester, VA 22601
ADMINISTRATIVE USE ONLY
Annual Gross Income ba
sed on information provided: $_________________________________
Incident Number #: _____________________
____ Approved
____ Claim Denied Due to: _________________________________________________________
Approval Signature: ______________________________________ Date: __________________
“To develop and deploy a coordinated service delivery system through which the community is provided
public safety services in a professional and cost effective manner."
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