Emergency Medical Services

Financial Assistance Application

This application is to receive discounted costs for Emergency Medical Services invoices received from service by the City of Tacoma Fire Department. Please note Financial Assistance is only available if all other resources available to the patient have been utilized, including private or public insurance, government programs, or any other third-party coverage.


This form takes about 15 minutes to complete, please be sure you have time to complete the full application as it cannot be saved. All four sections are required and must be completed.


All information you provide is used only for financial assistance consideration and will become part of your medical record with Tacoma Fire Department. This application is covered by the HIPAA Privacy Policy of our organization, which can be accessed here: TFD Privacy Notice.

SECTION 1 Patient Information

A Social Security Number is not required, however providing one will speed up the processing of your application.

Phone

SECTION 2 Household Family Information

Please provide information for all members of your household family. "Family" includes people related by birth, marriage, or adoption that reside together. All fields are required unless marked as 'optional'.

Person #1 should be the patient/yourself.

Check the box to add information for another member of your family household. If your list is complete, leave unchecked and move to SECTION 3.

Check the box to add information for another member of your family household. If your list is complete, leave unchecked and move to SECTION 3.

Check the box to add information for another member of your family household. If your list is complete, leave unchecked and move to SECTION 3.

Check the box to add information for another member of your family household. If your list is complete, leave unchecked and move to SECTION 3.

SECTION 3 Income Information

Please provide copies (pictures, PDFs, etc.) of all income sources you listed in SECTION 2 for all persons. If you have no proof of income, please provide a statement in the box below how you support your current expenses. Failure to provide documentation of your income sources will result in a declined application.


Sources of income include, but not limited to:

  • Wages (employer or self-employed)
  • Unemployment benefits
  • Worker's compensation
  • Social Security (including SSI, SSDI)
  • Child/Spousal support
  • Pension benefits
  • Rental/Investment income


Examples of proof of income include your most current:

  • W-2 withholding statement
  • Pay stubs (2 months)
  • Income tax return
  • Written statements from employer(s)
  • Social Security benefit statement
  • Approval/denial of eligibility for unemployment compensation

If you are not able to upload documents or images, please mail them, with your full name and phone number, to PO Box 111630, Tacoma, WA 98411.

Drag and drop files here or

If you have no proof of income to upload, please provide a statement in the box below how you support your current expenses.

SECTION 4 Terms & Conditions

By submitting this application, I understand and agree:

  1. I may be requested to provide additional documentation in order to complete this application process.
  2. All financial resources have been provided to the Tacoma Fire Department, including private or public insurance, government programs, or any other third-party coverage.
  3. Submitting this application does not guarantee eligibility or enrollment in the program.
  4. Approved financial assistance is valid for a period of two years from the date of approval and I will re-certify if financial assistance is needed after that time.
  5. I will notify Tacoma Fire Department regarding any household changes including change of address, increase or decrease in the number of occupants, and/or changes in income.
  6. Any violations of Tacoma Fire Department policies or the City of Tacoma Municipal Code may make my household ineligible for the EMS Financial Assistance Program.
  7. If I do not complete Sections 1-4 of this application and provide all required and requested documents, my application will not be processed.

By typing your name below, you certify you have read and agree to the Terms & Conditions above and you certify your application is complete and accurate to the best of your knowledge.

Questions?

If you have questions about using this form, or our financial assistance policy, please contact us at (253) 591-5844 or TFDBilling@tacoma.gov. Our office hours are Monday through Friday - 8:00 AM to 5:00 PM, excluding holidays. Thank you.

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