Application For Sbl Financial Assistance printable pdf download

Sarah Bush Lincoln

To apply for the IL Hospital Uninsured Discount, proof

Financial Assistance Program

of residency and one of the following proof of income

Important:

documents is required: recent tax return; W-2 or 1099;

YOU MAY BE ABLE TO RECEIVE FREE OR DISCOUNTED CARE:

two most recent pay stubs; written verification from

Completing this application will help Sarah Bush

employer; or one other reasonable form of income

Lincoln determine if you can receive free or

verification.

discounted services or other public programs that

can help pay for your healthcare. Please submit this

Copies of the following forms must be submitted

application to Sarah Bush Lincoln/Patient Financial

with your application (if applicable) to apply for all

Services department.

other financial assistance programs:

IF YOU ARE UNINSURED, A SOCIAL SECURITY

NUMBER IS NOT REQUIRED TO QUALIFY FOR FREE OR

q Most recent tax forms. Last two years for those who

DISCOUNTED CARE. However, a Social Security Number

are self employed.

is required for some public programs, including

q Most recent check stub(s) from all jobs.

Medicaid. Providing a Social Security Number is not

q Unemployment check stub listing start date and

required, but will help the hospital determine whether

amount.

you qualify for any public programs.

q Divorce decree stating child support paid or

alimony & child support received.

Please complete this form and submit it to Sarah

Bush Lincoln/Patient Financial Services department

q Letter from public programs (Social Security,

in person or by mail to apply for free or discounted

Veterans, Public Aid) listing amount received.

care within 240 days following the date the first

q Verification of all other income.

billing statement is mailed to the patient.

q Public Aid approval or denial letter if applicable -

pregnant, dependent children, disabled, blind,

Patient acknowledges that he or she has made a

Enhanced to better serve people

over age 65.

good faith effort to provide all information requested

with greater financial needs.

in the application to assist Sarah Bush Lincoln in

Bills will continue to be sent until a completed

determining whether the patient is eligible for

application is returned. Before the application may

financial assistance.

be processed, copies of supporting forms must be

We will work with community members to help

submitted with application or mailed to:

simplify the business aspect of our relationship.

Patient Financial Services

For example, we will help patients obtain payment

from third parties such as Medicaid and Medicare by

Sarah Bush Lincoln

answering their questions and assisting them with

1000 Health Center Drive; PO Box 372

applications. We offer financial assistance for persons

Mattoon, IL 61938

who meet the financial terms once they’ve submitted

the necessary paperwork, and we invite patients to

apply for financial assistance when they cannot cover

account balances after we’ve received payments

from third-party payers (like Medicaid, Medicare and

insurance companies).

If you have any questions about the SBL Financial

The mission of Sarah Bush Lincoln

Assistance Program, please call Patient Financial

is to provide exceptional care for all

Services between 8 am and 4:30 pm, Monday

and create healthy communities.

through Friday at (800) 381-0040.

Financial Assistance forms may be downloaded

from

Revised 06/2016

Application For Sbl Financial Assistance

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