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1. Parties: Identifies the ambulance service provider and the individual/entity requesting the fee waiver
2. Background: Explains the context of the ambulance service provided and the reason for the fee waiver request
3. Definitions: Defines key terms used in the document including 'Ambulance Services', 'Fees', 'Service Date', etc.
4. Services Rendered: Details of the specific ambulance service(s) provided, including date, location, and nature of service
5. Fee Details: Specifies the original fees being waived and any partial payments or remaining balances
6. Waiver Terms: The actual waiver provisions, clearly stating which fees are being waived and under what conditions
7. Release of Claims: Statement releasing the service provider from future claims related to the fees being waived
8. Governing Law: Specifies that the agreement is governed by relevant Canadian provincial laws
9. Execution: Signature blocks and date of execution
1. Multiple Incidents: Section to be included when the waiver covers multiple service dates or incidents
2. Insurance Claims: Include when there are pending or potential insurance claims related to the service
3. Third Party Authorization: Required when someone other than the patient is authorized to sign the waiver
4. Partial Waiver Terms: Include when only a portion of the fees are being waived
5. Future Services: Include when the waiver extends to potential future services
6. Confidentiality: Optional section regarding the confidentiality of the waiver agreement and related medical information
1. Schedule A - Fee Breakdown: Detailed breakdown of the ambulance service fees being waived
2. Schedule B - Service Details: Specific details of the ambulance service(s) including times, locations, and nature of emergency
3. Schedule C - Insurance Information: Details of any insurance coverage or claims related to the service
4. Appendix 1 - Supporting Documentation: Any relevant supporting documents such as medical necessity forms or financial hardship evidence
Healthcare
Emergency Services
Medical Transport
Public Health
Insurance
Municipal Services
Social Services
Legal
Finance
Patient Accounts
Emergency Services Administration
Billing and Collections
Compliance
Patient Relations
Risk Management
Operations
Policy and Procedures
Emergency Services Director
Healthcare Administrator
Financial Services Manager
Patient Accounts Coordinator
Billing Specialist
Legal Compliance Officer
Patient Relations Manager
Medical Services Coordinator
Emergency Medical Services Supervisor
Revenue Cycle Manager
Healthcare Policy Advisor
Risk Management Officer
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