Charity care application ny 2026

1. Click ‘Get Form’ to open the charity care application in the editor.
2. Begin by entering the patient’s name, date of birth, and contact information in the designated fields. Ensure accuracy as this information is crucial for processing your application.
3. Next, provide details about your occupation and employer. Fill in the employer's address and telephone number to complete this section.
4. In the income section, list all sources of income for yourself and any household members. Be thorough; include wages, self-employment earnings, public assistance, and other relevant types of income.
5. Calculate and enter your total income for the last three months and twelve months. Remember to attach documentation that supports your reported income.
6. Indicate your family size by listing each member living in your household along with their age and relationship to you. If more space is needed, feel free to attach an additional sheet.
7. Finally, read the statement regarding eligibility verification carefully. Sign and date where indicated before submitting your completed application to NewYork-Presbyterian Hospital.

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