top of page
NorthJeff78_edited.png

Easily Access Important Forms Online

The District aims to provide simple resources to the community for submitting insurance information, requesting medical records, applying for financial assistance, and filing a claim through the Crime Victims' Compensation Program. Use our online forms to send information quickly and securely.

Crime Victims' Compensation Program

NorthJeff183_edited.jpg

The Department of Public Safety Missouri Office for Victims of Crime offers the Crime Victims' Compensation Program for individuals who have suffered physical trauma from specific violent crimes. The program provides a maximum benefit of $25,000.

Medical Records Request

Patients who have received emergency medical care and assistance from the District can request to receive all medical records related to these services. Complete the medical records request form and submit it electronically. The District works to facilitate all requests promptly.

NorthJeff39_edited.jpg
NorthJeff83_edited.jpg

Apply for Financial Assistance

District residents will never pay an ambulance service bill beyond the amount covered by their private insurer, Medicaid, or Medicare. Those outside the District might accrue charges related to deductibles and out-of-pocket expenses. The District understands that, in some cases, the cost of medical bills leads to financial hardships. The District offers financial assistance for individuals who cannot afford their ambulance bills.

Individuals applying for assistance must meet certain income requirements. To apply for assistance, complete the application and submit all necessary documents.

Insurance Authorization Form

The District requires permission from patients to bill insurance providers, Medicaid, or Medicare for any administered medical services. Complete the signature authorization form to facilitate the claims process.

bottom of page