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CHARITY CARE/FINANCIAL ASSISTANCE APPLICATION FORM -CONFIDENTIAL

SCREENING INFORMATION

Do you need an interpreter?

Yes

If Yes, list preferred language:

Has the patient applied for Medicaid?

Yes

May be required to apply before being considered for financial assistance

Does the patient receive state public services such as TANF, Basic Food, or WIC?

Yes

Is the patient currently homeless?

Yes

Is the patient's medical care need related to a car accident or work injury?

Yes

PLEASE NOTE:

We cannot guarantee that you will qualify for financial assistance, even if you apply.
Once you send in your application, we may check all the information and may ask for additional information or proof of income.
Within 14 calendar days after we receive your completed application and documentation, we will notify you if you qualify for assistance.

PATIENT AND APPLICANT INFORMATION

Patient First name

Patient Middle Name

Patient Last Name

Gender

Male

Female

Other

Birth Date

Patient Social Security Number

Person Responsible for Paying Bill

Relationship to Patient

Birth Date

Social Security Number

Mailing Address

City

State

Zip Code

Main Contact Phone Number 1

Main Contact Phone Number 2

Main Contact Email

FAMILY INFORMATION

List family members in your household, including you. "Family" includes people related by birth, marriage, or adoption who live together.

Family Size

Family Member 1

Name

Date of Birth

Relationship to Patient

If 18 years old or older: Employer(s) name or source of income

If 18 years old or older: Total gross monthly income (before taxes):

Also applying for financial assistance?

Yes

Family Member 2

Name

Date of Birth

Relationship to Patient

If 18 years old or older: Employer(s) name or source of income

If 18 years old or older: Total gross monthly income (before taxes):

Also applying for financial assistance?

Yes

Family Member 3

Name

Date of Birth

Relationship to Patient

If 18 years old or older: Employer(s) name or source of income

If 18 years old or older: Total gross monthly income (before taxes):

Also applying for financial assistance?

Yes

Family Member 4

Name

Date of Birth

Relationship to Patient

If 18 years old or older: Employer(s) name or source of income

If 18 years old or older: Total gross monthly income (before taxes):

Also applying for financial assistance?

Yes

ALL ADULT FAMILY MEMBERS' INCOME MUST BE DISCLOSED. SOURCES OF INCOME INCLUDE, FOR EXAMPLE:

-Wages -Unemployment -Self-Employment -Worker's Compensation

-Disabiliy -SSI -Child/Spousal Support -Work Study Programs (students) -Pension -Retirement Account Distributions -Other

INCOME INFORMATION

REMEMBER: You must include proof of income with your application

You must provide information on your family's income. Income verification is required to determine financial assistance. All family members 18 years or older must disclose their income. If you cannot provide documentation, you may submit a written signed statement describing your income. Please provide proof for every identified source of income. Examples of proof of income include:

A "W-2" withholding statement; or
Current pay stubs (3 months); or
Last year's income tax return, including schedules if applicable; or
Written, signed statements from employers or others; or
Approval/denial of eligibility for Medicaid and /or state-funded medical assistance; or
Approval/denial of eligibility for unemployment compensation.

If you have no proof of income or no income, please attach an additional page with an explanation.

Please upload one or two of the documents described above:

EXPENSE INFORMATION

We use this information to get a more complete picture of your financial situation.

Monthly Household Expenses:

Rent/Mortgage: $

Insurance Premiums: $

Medical Expenses: $

Utilities: $

Other Debt/Expenses: $ (Child support, loans, medications, other)

ASSET INFORMATION

This information may be used if your income is above 101% of the Federal Poverty Guidelines.

Monthly Household Expenses:

Current checking account balance: $

Current savings account balance: $

Does your family have these other assets?

Please Check all that apply

Stocks

Bonds

401K

Trust(s)

Health Savings Account(s)

Property (excluding primary residence)

Own a business

ADDITIONAL INFORMATION

Please attach an additional page if there is other information about your current financial situation that you would like us to know, such as a financial hardship, excessive medical expenses, seasonal or temporary income, or personal loss.

PATIENT AGREEMENT

I understand that Othello Community Hospital may verify information by reviewing credit information and obtaining information from other sources to assist in determining eligibility for financial assistance or payment plans.

I affirm that the above information is true and correct to the best of my knowledge. I understand if the financial information I give is determined to be false, the result may be denial of financial assistance, and I may be responsible for and expected to pay for services provided.

Date

Month

Day

Year

Signature of Person Applying

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Acerca de

(English)

CHARITY CARE/FINANCIAL ASSISTANCE APPLICATION FORM -CONFIDENTIAL

SCREENING INFORMATION

PATIENT AND APPLICANT INFORMATION

FAMILY INFORMATION

INCOME INFORMATION

EXPENSE INFORMATION

ASSET INFORMATION

ADDITIONAL INFORMATION

PATIENT AGREEMENT

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