Financial Assistance Application (FAA)

Transcription

1 Financial Assistance Application (FAA) Patient Demographics Patient Name: Last, First, Middle Guarantor Name: Last, First, Middle Social Security # (If available) Social Security # (If available) Date of Birth Account # Location of Service Date of Birth Relationship to Patient Patient/ Guarantor Address County of Residence Home Phone # Alternate Phone # City State Zip Code Homeowner? Yes No Have you applied for Medicaid or any other State/County Assistance? (Circle one) Yes No If Yes, Please provide the following: Application Date: Caseworker Name: Status of Application: Caseworker Phone Number: Household Information Marital Status: Married Single Separated Divorced Widowed Dependent Names Relationship Date of Birth Employment/Household Income and Expenses Patient/Guarantor Employer Name Gross Monthly Income: $ Provide verification If income is $0, please explain. Provide documentation Spouse s Employer Name Gross Monthly Income: $ Provide verification If income is $0, please explain. Provide documentation Other Income Source: Gross Monthly Income: $ Provide verification EXPENSES ARE NOT REQURIED FOR NHSC APPLICATIONS Household Monthly Expenses Total Monthly Expenses: $ IMPORTANT: To qualify for assistance, at least one piece of supporting documentation that verifies household income may be required. Supporting documentation can include but is not limited to, most recent year s tax return, a current W-2, 1 month of current pay-stubs, signed letter of support, etc.

2 PLEASE READ THE FOLLOWING BEFORE SIGNING AND DATING THE APPLICATION Please be advised that your signature indicates you have agreed to attach income verification. I certify that the information I have provided is true and accurate to the best of my knowledge. I will independently or with the assistance of hospital personnel apply for ANY and ALL Assistance which may be available through federal, state, local government and private sources to help pay this healthcare bill. I understand that if I do not cooperate with my healthcare provider in providing requested information, my application may be denied for possible financial assistance. I understand that the information which I submit is subject to verification by my healthcare provider, including credit reporting agencies and subject to review by Federal and/or State agencies and others as required. I understand that additional information may be requested in order to qualify for assistance. Signature (Applicant/Guarantor) Date Return Completed Application and Documents to: CHI Memorial Attn: Financial Assistance Center Phone: (844) Fax: (469)

3 Reason for visit: Office Use Only FPL% Total Charges: $ Total Adjustment: $ Verification Documents: YES NO Identification/Address: Driver s license, picture ID, or other Family Size/Income: Tax return, pay stubs, or other Approval (s): Name (Printed) Name (Signature) Title Date Name (Printed) Name (Signature) Title Date Name (Printed) Name (Signature) Title Date Name (Printed) Name (Signature) Title Date Comments:

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5 Contact Information: Centralized Charity Center Frisco Assistance Center State Contact phone number Correspondence or physical address (Send your FAA) Arkansas St. Vincent Infirmary Medical Center Arkansas St. Vincent Morrilton Arkansas St. Vincent Medical Center - Iowa Community Memorial Attn: EES/MECS Iowa Mercy Corning Attn: EES/MECS Iowa Mercy Council Bluffs Attn: EES/MECS Iowa Mercy Des Moines Attn: EES/MECS th Ave. Des Moines, IA Iowa Mercy West Lakes Attn: EES/MECS th Ave. Des Moines, IA Iowa Mercy Centerville Attn: EES/MECS th Ave. Des Moines, IA Iowa Skiff Medical Center and Attn: EES/MECS 204 N. 4th Ave. E Newton, IA 50208

6 Continuing Care Flaget Memorial Jewish Med Center East Med Center east Med Center Southwest Med Center South Jewish Shelbyville Our Lady of Peace Saints Mary and Elizabeth Frazier Rehab Institute Southern Indiana Rehab Saint Joseph Saint Joseph Berea

7 Saint Joseph East Minnesota Saint Joseph Jessamine Saint Joseph London Saint Joseph Martin Saint Joseph Mt. Sterling University of Louisville LakeWood Health Center or Attn: EES/MECS PO Box 7 Mt. Sterling, KY Attn: Admissions Department 530 South Jackson Street Minnesota St. Francis Healthcare Minnesota St. Gabriel's Minnesota St. Joseph's Area Health Services CHI Health Saint Elizabeth regional CHI Health Saint Francis CHI Health Good Samaritan Attn: EES/MECS 555 S 70th Street Lincoln NE Attn: EES/MECS 10 East 31st Street Kearney NE Attn: EES/MECS 10 East 31 st Street Kearney NE 68847

8 CHI Health Saint Mary's CHI Health Heart Attn: EES/MECS 1301 Grundman Blvd City NE Attn: EES/MECS 7440 S 91st Street Lincoln NE Bergan Mercy Attn: EES/MECS 2301 N. 117th Ave. Ste. 100 Creighton Univ Med Ctr Immanuel Medical Center Attn: EES/MECS Attn: EES/MECS Midlands Attn: EES/MECS Lakeside Attn: EES/MECS Lasting Hope Recovery Center Memorial Schuyler Plainview Attn: EES/MECS Attn: EES/MECS Attn: EES/MECS Carrington Health Center Lisbon Area Health Services Mercy Devil s Lake Mercy Valley City

9 Mercy Medical Center Williston Oakes Community St. Alexius Medical Center St. Alexius Garrison Memorial St. Joseph and Turtle Lake Community Memorial Oregon Oregon Mercy Medical (Roseburg, OR) St Anthony (Pendleton, OR) Attn: MECS Mercy Medical Center 2700 NW Stewart Parkway Roseburg, OR Attn: MECS St. Anthony 2801 St. Anthony Way Pendleton, OR Tennessee Memorial Tennessee Memorial Park Baylor St. Luke's Medical Center CHI St. Luke's Health- Lakeside CHI St Luke's Health Memorial Lufkin Eligibility and Enrollment Eligibility and Enrollment Attn: EES/MECS 1201 W Frank Lufkin TX 75904

10 CHI St Luke's Health Memorial Livingston CHI St Luke's Health Memorial San Augustine CHI ST Luke's Health Memorial Specialty CHI St. Luke s Health- Patients Medical Center CHI St. Luke s Health- Springwoods Village CHI St. Luke's Health- Sugar Land CHI St. Luke's Health- The Vintage CHI St. Luke's Health- The Woodlands St. Joseph Regional Burleson St. Joseph Bellville St. Joseph Madison St. Joseph Grimes St. Joseph Attn: EES/MECS Bypass Livingston TX Attn: EES/MECS 511 E St San Augustine TX Attn: EES/MECS 1201 Frank Ave Ste. D5 Lufkin TX Patient Financial Services CHI St. Luke s Health PO Box Houston, Eligibility and TX Enrollment Eligibility and Enrollment Eligibility and Enrollment Eligibility and Enrollment Attn: EES/MECS 2801 Franciscan Drive Bryan, TX Attn: EES/MECS 2801 Franciscan Drive Bryan, TX Attn: EES/MECS 2801 Franciscan Drive Bryan, TX Attn: EES/MECS 2801 Franciscan Drive Bryan, TX Attn: EES/MECS 2801 Franciscan Drive Bryan, TX 77802

11 Washington Harrison Dallas, TX Washington Highline Dallas, TX Washington St Anthony Dallas, TX Washington St Clare Dallas, TX Washington St Elizabeth Dallas, TX Washington St Francis Dallas, TX Washington St Joseph Dallas, TX