For Internal use only
Account #_____________________
NYU Faculty Group Practice
Amount of W/O $_______________
Financial Assistance Application
Please mail or fax completed application to:
NYU Physician Services
P.O. Box 415662
Boston, MA 02241
Fax #: 678-459-0963
Patients treated in the NYU Langone Medical Center Faculty Group Practice (FGP) are responsible for paying all
applicable out-of-pocket costs associated with their care including copayments, co-insurances and/or deductibles.
The FGP Financial Assistance Program provides discounts for low-income individuals who do not have health
insurance or who have exhausted their health insurance benefits and meet certain income guidelines for eligible
services. Exclusions to this program include, but are not limited to, non-covered services and elective procedures
for patients who are enrolled in insurance plans which providers do not contract with.
To be eligible, a patient must be a US citizen or legal resident living in New York State or the state in which the
service is rendered. All applications will be reviewed and approved on a case-by-case basis.
Name (Last, First, MI)
Date of Request
Street Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
(
)
Preferred
(
)
Preferred
(
)
Preferred
SSN
Date of Birth
Marital Status
□ Single □ Married □ Divorced □ Widowed □ Separated □ Partner □ Other:
Citizenship
Current Insurance Status
□ Insured □Uninsured □ Applying for a Government Program □ Other:
Patient Employment Status
Guarantor Employment Status
□ Full-time □ Part-time □ Unemployed □ Retired □ Other:
□ Full-time □ Part-time □ Unemployed □ Retired □ Other:
Last Day Worked (if applicable)
Last Day Worked (if applicable)
Monthly Salary/Unemployment/Disability Income
Monthly Salary/Unemployment/Disability Income
Other Monthly Income (Rental, Investment, Pension or Other)
Other Monthly Income (Rental, Investment, Pension or Other)
Spouse Employment Status
Comments:
□ Full-time □ Part-time □ Unemployed □ Retired □ Other:
Last Day Worked (if applicable)
Monthly Salary/Unemployment/Disability Income
Other Monthly Income (Rental, Investment, Pension or Other)
Household Size
Total Household Income
1
2
