Ambulance Hardship Waiver

The Ambulance Hardship Waiver is designed to help people who have no insurance or the means to pay.

With any questions about the waiver policy, call City of Madison Finance at (608) 267-8630.

Apply for a Waiver

Apply for a Waiver

Please prepare all required documents before applying. If you have any questions about the application portal, please call 877-618-0943.

Required Documents

  1. Signed statement. Statement indicating your insurance or governmental assistance. For example: "I have no assistance or insurance to cover this ambulance bill."
  2. Proof of total family income. A signed copy of your most recent federal income tax form, including social security (line 20a).
    • If you did not file taxes, submit proof of income or hardship such as:
      • A photocopy of your most recent signed Homestead Schedule H.
      • A photocopy of a Statement of Benefits from either Food Share, SSI, Disability, or Unemployment.
      • Copy of Hospital Charity Care Approval for the same date of service.
      • Copy of Student Financial Aide and/or Work-Study documents.
  3. Explanation of governmental assistance benefits and payments. If you are receiving or eligible for governmental assistance such as medical assistance, Medicare, or Social Security Income (SSI), send an explanation of benefits and payments.
  4. Explanation of private insurance. If you have private health or accident insurance, it must be applied for before you apply for a waiver. When you receive a check or denial, send us the payment and the explanation of benefits that you received.

Failure to completely and accurately provide the required information may result in denial of the waiver.

Percent of Fee Waived

The schedule below provides the percent of fee waived based on total family income and number of individuals in household.

Total Family Income Number of People in Household
1 2 3 4+
$0 - $40,770 100% 100% 100% 100%
$40,771 - $47,850 80% 100% 100% 100%
$47,851 - $54,930 60% 100% 100% 100%
$54,931 - $62,010 40% 80% 100% 100%
$62,011 - $69,090 20% 60% 100% 100%
$69,091 - $76,170 0 40% 80% 100%
$76,171 - $83,250 0 20% 60% 100%
$83,251 - $90,330 0 0 40% 80%
$90,331 - $97,410 0 0 20% 60%
$97,411 - $104,490 0 0 0 40%
$104,491 - $111,570 0 0 0 20%
$111,571+ 0 0 0 0