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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Patient Demographics section. Enter your name, facility, account number, social security number, and date of birth accurately.
Complete the Guarantor Information by providing the guarantor's name, social security number, date of birth, address, and phone number.
In the Household Information section, indicate your marital status and total number of individuals in your household.
For Employment/Income details, list your employer's name and gross monthly income. Attach any necessary verification documents as specified.
Fill out the Insurance Verification section by answering questions about health insurance availability and employment status.
Review all information for accuracy before signing at the bottom of the form to certify that all provided information is true.

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What does financial assistance cover?

FAPs must apply to all emergency and medically necessary care furnished by the hospital and substantially related entities. If emergency and medically necessary care is provided by the hospital facility, the care must be covered under the FAP. Check for a Provider List.

What does charity care cover in NC?

The Charity Care Program insures that all eligible individuals receive medically necessary care at participating UNC Health Care entities regardless of their ability to pay. The program is available for patients with a household income of at or below 250% of the Federal Poverty Guideline for their family size.

What is the class action lawsuit against Novant Health?

The lawsuit against Novant Health was filed on behalf of 10 Novant Health patients and similarly situated individuals who used the patient portal while the Meta Pixel code was present and alleged invasion of privacy, bdocHub of contract, and violations of the Health Insurance Portability and Accountability Act (HIPAA).

What is the phone number for Novant Health financial Services?

Contact Novant Health: Digital Products Services (DPS) 1-866-9-NOVANT (966-8268).

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