Dear Patient/Applicant,

MESTA EMS is driven by compassion and dedicated to providing personalized care for all – especially those most in need. It is our mission and privilege to offer financial assistance to our patients. Financial assistance is available only for emergencies and other medically necessary care. Thank you for trusting us to care for you and your family for all your healthcare needs.

Please complete both sides, including your signature and date before returning it. If you completed an application within the past six months and were approved for financial assistance, please notify us – you may not need to complete a new application. Unfortunately, we are unable to rely on a prior application that is greater than six months old.

Along with the application, you will need to provide verification of your household’s income and verification of all assets owned by any household member.

Examples of proof of income and assets include:

• Copies of 3 most recent paystubs from employer

• Copies of most recent yearly tax return (if self-employed, include all schedules)

• Social Security and/or Pension Retirement Award Letter

• Parent or guardian’s most recent yearly tax return, if applicant is a dependent listed on

their tax form and under the age 25

• Copy of receipt of unemployment benefits

• Approval/denial of eligibility for Medicaid and/or state-funded medical assistance

• Other income validation documents

Examples of proof of assets include:

• Current bank statements (checking and savings accounts) from last 3 months

• Investments, including stocks and bonds

• Trust funds

• Money market accounts

• Mutual funds

If you receive assistance from or live in a home with a family or friends, please have them complete the attached form labeled “Letter of Support.” This will not make them responsible for your medical bills. This will help show how you are able to afford living expenses. If you do not receive assistance from family and friends, you do not need to fill out the Letter of Support form.

Finally, we may be able to consider your outstanding medical bills to qualify you for financial assistance. If you would like us to consider this, please also provide documentation of your outstanding monthly medical and pharmacy/drug costs, such as current invoices or statements of account balances.

Please know that the 1) completed application along with 2) proof of income, 3) assets, and 4) outstanding medical bills (if applicable) must be received for the application to be considered. We are unable to process or consider applications that are not complete.

When submitting your application, please keep in mind that communications via email over the internet are not secure. Although it may be unlikely, there is a possibility that information you include in an email may be intercepted and read by other parties besides the person to whom it is addressed. We want to protect your personal information and ensure that it remains secure. Since the application contains your social security number and other private information, we urge you to refrain from emailing it.

Please print and mail your completed application and supporting documentation to the following address:

MESTA

Attention Director

4144 Redden Street

Pryor, OK. 74361

We are here to help, and want to ensure that patients that qualify for financial assistance receive it. If you have any questions about this application, supporting documents required, or how to best get your application to us, please call our office at 918-825-6825