Moses Lake, WA · Grant County
Medicaid Exemption for Ambulance Utility
Medicaid-eligible residents use this application to request an exemption from the ambulance utility fee on their Moses Lake utility account.
What this form is
This application requests an exemption from the ambulance utility fee for eligible Medicaid recipients who receive in-home services or live in a skilled nursing facility, boarding home, or adult family home. Each person claiming the exemption must file annually and attach proof of eligibility, such as a current Medicaid ID card, Medicaid coupon, or DSHS award letter. The applicant provides resident and service address details, utility account number, signature, and date.
Who needs it
A Medicaid-eligible resident receiving in-home services or living in a listed care facility must file annually to claim the ambulance utility fee exemption.
How to submit it
Return the completed form with proof of eligibility to Moses Lake Fire Department, 701 E 3rd Ave, Moses Lake, WA 98837.
About notarization
This form is signed without a notary; the applicant instead declares the information true under penalty of perjury and attaches proof of Medicaid eligibility.
How to submit this form
- 1
Download The Application
Download the Medicaid Exemption for Ambulance Utility form.
- 2
Complete The Form
Enter the date, resident name, service address, and utility account number, then sign and date the form.
- 3
Attach Proof Of Eligibility
Attach a current Medicaid ID card, current Medicaid coupon, or DSHS award letter.
- 4
Return The Application
Send the completed form and proof to Moses Lake Fire Department at the address listed on the form.
Frequently asked questions
- Who can apply for the ambulance utility fee exemption?
- Applicants must be Medicaid eligible and receive in-home services at their personal residence or live in a skilled nursing facility, boarding home, or adult family home.
- What proof of eligibility should I attach?
- Attach a copy of your current Medicaid ID card, a copy of your current Medicaid coupon, or an award letter on DSHS letterhead.
- How do I submit the Medicaid exemption form?
- Return the completed form and proof of eligibility to Moses Lake Fire Department, 701 E 3rd Ave, Moses Lake, WA 98837.
- Do I need a notary for the Medicaid exemption form?
- No. The form is signed without a notary; the applicant declares the information true under penalty of perjury and attaches proof of Medicaid eligibility.
Need something notarized?
This Medicaid Exemption for Ambulance Utility doesn’t need a notary — but if you have another Moses Lake form that does, a commissioned online notary can help.