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AMBULANCE BILLING FORMS

The District of Columbia Fire and EMS Department (DCFEMS) provides this webpage as a resource for patients, insurers, attorneys, and healthcare facilities to access and download forms required for ambulance billing. Currently, all required forms are only available for download in portable document format (PDF). Electronic forms will be available prior to January 1, 2022.

If you need help completing forms, including understanding the forms in a language other than English, have difficulty reading the forms, or are unsure what to do, please call the DCFEMS third party billing service office representative at 1-202-673-3368 during normal business hours.

PATIENT FORMS

If you are requesting hardship reduction or waiver of an unpaid patient account balance after insurance claim processing is complete (if you are insured), you (or your representative) must complete and submit a hardship request form. Reasons for hardship (on the date of ambulance transport) include the following:

  • Patient was homeless.
  • Patient was unemployed.
  • Patient was uninsured.
  • Patient was (or is) permanently disabled.
  • Patient was experiencing an end-of-life medical condition or died following ambulance transport.
  • Other reasons, subject to review.

Please click this link to download a hardship request form. Please complete and mail the form to the address shown below. The DCFEMS third party billing service will review your request. If approved, your ambulance fees and charges will be reduced or waived, and you will have limited (or no) financial responsibility for account balance payment and will be ineligible for collection of unpaid account balances if full payment is made at adjusted rates determined by the review (when applicable).

If you are requesting insurance review reduction or waiver of an unpaid patient account balance after insurance claim processing is complete, you (or your representative) must complete and submit an insurance review form. Reasons for insurance review include the following:

  • Patient was not identified as having insurance on the date of ambulance transport, when such a patient submitted insurance coverage information, and the claim filing deadline has expired.
  • Patient experienced an insurance claim processing error, when such error resulted in claim rejection or denial, and the claim re-filing deadline has expired.
  • Patient experienced insurance claim denial, or an insurer did not respond to a claim, and the claim was re-filed without further action by an insurer or another insurer.
  • Patient experienced a high out-of-pocket unpaid balance (more than $500), when such a balance was the result of an insurer applied deductible and/or co-pay.
  • Patient experienced involuntary ambulance transport, and an insurer denied or did not respond to the claim.
  • Other reasons, subject to review.

Please click this link to download an insurance review form. Please complete and mail the form to the address shown below. The DCFEMS third party billing service will review your request. If approved, your ambulance fees and charges will be reduced or waived, and you will have limited (or no) financial responsibility for account balance payment and will be ineligible for collection of unpaid account balances if full payment is made at adjusted rates determined by the review (when applicable).

If you are requesting reduction or waiver of an unpaid patient account balance for other reasons of necessity after insurance claim processing is complete, you (or your representative) must complete and submit an identity dispute form, submit a letter requesting reduction or waiver, or call the DCFEMS third party billing service office representative at 1-202-673-3368 during normal business hours to explain the reason. Other reasons for reduction or waiver include the following:

  • The person making a request was not the patient identified by an account number, date of service, or other information provided to the DCFEMS third party billing service, or was fraudulently identified as the patient because of identity theft.
  • Patient receiving ambulance transport was the victim of a crime.
  • Other reasons, subject to review.

Please click this link to download an identity dispute form. Please complete and mail the form to the address shown below. The DCFEMS third party billing service will review your request. If approved, your ambulance fees and charges will be waived, and you will have no financial responsibility for account balance payment and will be ineligible for collection of unpaid account balances.

Other reasons are subject to individual review. If approved, your ambulance fees and charges will be waived, and you will have no financial responsibility for account balance payment and will be ineligible for collection of unpaid account balances.

Please submit all completed forms, attached documents and/or letters by mail to:

DC Fire and EMS Department
P.O. Box 27767
Washington, DC 20038