Financial Assistance Application Form printable pdf download

Financial Assistance Application Form

SECTION ONE: PATIENT INFORMATION Please complete all information noted in this section

Medical Record Number: ____________________

Applicant Name: ______________________________________________________________

LAST

MIDDLE INITIAL

FIRST

Address:________________________________________________________ City:____________________ County:________________________

State of Residence:___________________________ Zip Code:________________ Primary Phone: (________) ___________________________

Marital Status:  Single  Married  Divorced

Are you a US Citizen:  Yes  No If no, are you a legal resident of the United States:  Yes  No

Employer Name: _________________________________________________ Address: ________________________________________________

Secondardy/Spouse Employer Name: ________________________________ Address: ________________________________________________

Is insurance offered through Employer:  Yes  No If yes, provide cost of employee portion _________________________________________

Did you have health insurance (other than Medicaid) at the time of your service? Yes  No If yes, please provide your insurance info and a copy of your insurance card

Name of Insurance:

Effective Date: _____/_____/____

Subscriber Name: _________________________________________ Subscriber ID: __________________ Group #: ____________________

Have you applied for Medicaid coverage?  Yes  No

If Yes, what is the status?  Approved  Pending  Denied

Have you applied for coverage through the Healthcare.gov Insurance Marketplace?  Yes  No

SECTION TWO: FAMILY INCOME Please provide income for yourself, your spouse and all other household members

Monthly Income

Total Family Income for 1 month prior to

Type of Income verification attached Proof of income is required

Source

date of service

to process your application

Copy of most recent federal tax return (or form 4506t), pay stubs for the last 30

Wages/Self Employment

days

Social Security award letter

Social Security

Pension, Dividends, Interest,

Pension benefits letter, Dividend/Interest Statement

Rental Income

Unemployment, Workers’

Unemployment benefit letter, Workers’ Compensation benefit letter

Compensation

If you reported $0 income, please provide a brief explanation of how you (or the patient) are meeting basic living needs. Please also provide a letter of support from any

individual assisting you: _____________________________________________________________________________________________________

SECTION THREE: MEDICAL EXPENSES Medical expenses will be considered as an offset to income

Medical Bill Type

Monthly Amount Paid

Verification Required

Hospital and Physician Bills (Non-WVU Healthcare providers)

Copies of bills

Prescription Drugs

Pharmacy receipt print out

Other Medical Expenses

Page 1

Policy II.015 Exhibit I Eff 01/01/2015