Hardship Request

The City of St. Charles abides by the contractual and legal obligations of health benefit plans to collect charges, co-payments, co-insurance, and deductible amounts owed by patients.

Recognizing that circumstances may arise where an individual is unable to pay in full at the time of service, the City of St. Charles has adopted a policy of screening requests for discounts, delayed payment plans, and debt forgiveness based upon individual circumstances.

In order to accomplish this in a fair and equitable manner, we must ask for certain financial information to demonstrate need.

Please complete the Ambulance Billing Financial Hardship Application (PDF), providing the requested supporting documentation, and mail to:
Emergency Medical Services Management and Consultants
Attn: Mailroom
P.O. Box 863
Lewisville, NC  27023

Completing the request does not guarantee assistance. Please continue to follow-up on your account in a timely manner. If you need assistance completing the application or have additional questions, please contact our ambulance billing office at 336-766-4448 or 800-814-5339.