To obtain a printable PDF copy of our forms, please click the document name below:
North Jefferson County Ambulance District offers financial assistance to make healthcare affordable and accessible to members of the community. We also provide discounted and charity care for eligible individuals. If payment of your healthcare expenses could create a financial hardship for you, you may qualify for financial assistance.
Am I eligible?
- Household income, in relation to federal poverty guidelines
- Any additional financial hardship
- Medically necessary care
- The account must be a current, non-collection referred account
How do I apply?
Complete the financial assistance application. Along with the application, you must submit all of the following documents that apply to you and your household;
- Copies of most recent Federal Income Tax Return for each household member(s)
- Copies of most recent W-2's for each household member(s)
- Copies of the 3 most recent paycheck stubs or a statement of earnings from each household member(s) employer
- Copies of unemployment and/or disability compensation statements for each household member(s)
- Copies of Social Security or pension income for each household member(s)
- Copies of government assistance notices, such as Social Security Disability and Medicaid Programs for each household member(s)
Where do I send my completed application & documentation to?
Your application and documentation can be sent the following ways;
- Secured Fax
North Jefferson County Ambulance District2820 Horrell LaneHigh Ridge, MO 63049