Charity Care
Policy:
- At Town of Montgomery Emergency Medical Services, our goal is to provide quality emergency care to our patients. We seek to provide services to everyone regardless of ability to pay. That is why we provide patients with the opportunity to qualify for our Charity Care Program whether you are uninsured or underinsured. Our Charity Care Program is based on the Federal Poverty Guidelines, and is available to all patients that qualify. The application must be filled out and all supporting documents must be sent in at the time of filing. Decisions of eligibility will be made within 30 days or application being submitted. Town of Montgomery Emergency Medical Services will not charge patients for its Charity Care Program more than the amount generally billed to individuals who have insurance for emergency medical care.
How to apply for Charity Care:
- An evaluation of the patient’s financial situation will be completed with the use of a Charity Care Application and supporting documents from the patients/ responsible party as listed below.
- Application must be filled out entirely. Write N/A if box does not pertain to your situation.
- All supporting documents must be submitted with the Charity Care Application.
- Application must be signed and dated.
- Application should be mailed to 8610 Main Street, Williamsville, NY 14221 or faxed to (845)275-3008 within 30 days of first billing statement.
Sliding Scale for Uninsured and Uninsured 2025
| Family Size | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | Discount of Patient Responsibility |
|---|---|---|---|---|---|---|---|---|---|
| Federal Poverty Level | $27,861 | $37,814 | $47,767 | $57,720 | $67,673 | $77,626 | $87,579 | $97,352 | 100% |
| 200% FPL | $55,722 | $65,675 | $75,628 | $85,581 | $95,534 | $105,487 | $115,440 | $125,393 | 75% |
| 250% FPL | $69,652 | $79,605 | $89,558 | $99,511 | $109,464 | $119,417 | $129,370 | $139,323 | 50% |
| 300% FPL | $83,583 | $93,536 | $103,489 | $113,442 | $123,395 | $133,348 | $143,301 | $153,254 | 25% |
| 350% FPL | $97,513 | $107,466 | $117,419 | $127,372 | $137,325 | $147,278 | $157,231 | $167,184 | 0% |
(For each additional person over 8 people in the household add $9,953.00)
- Uninsured or underinsured patients under the 200% of the Federal Poverty Level will receive a 100% discount on patient responsibility.
- Uninsured or underinsured patients above the 200% of the Federal Poverty Level may qualify for additional discounts based on a sliding income scale above.
- Patients who cannot pay their entire bill immediately can request an interest free payment arrangement by calling our billing department at (845)275-3008.
- All self-pay patient or uninsured patients can also receive a Self-Pay Discount for timely payment as listed below:
- Payment in 30 days 50% discount for payment in full
- Payment in 60 days 40% discount for payment in full
- Payment in 90 days 25% discount for payment in full
Apply for Charity Care
Download and complete the application form below. Submit all required documents within 30 days of your first billing statement.