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Patient Financial Assistance Application

Patient Financial Assistance Application 2025

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The document is a Patient Financial Assistance Application form used to assess eligibility for financial aid based on family size, income, and assets. It requires personal information, income sources, expenses, and documentation to determine the level of assistance available. The application also includes specific instructions regarding separate billing for anesthesiology and pathology services.

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Click ‘Get Form’ to open the Patient Financial Assistance Application in our editor.
Begin by filling in your personal information, including your name, phone number, address, date of birth, and social security number. Ensure accuracy as this information is crucial for eligibility assessment.
Indicate your marital status and the number of family members living with you. This helps determine your household size for financial evaluation.
Answer the employment questions by selecting 'Yes' or 'No'. If employed, provide details about your employer, length of employment, hourly wage, and gross monthly income.
List all sources of income and their amounts. Include any additional income such as Social Security or child support. Be thorough to ensure a complete financial picture.
Detail your monthly expenses in the provided sections. This includes housing costs, utilities, food expenses, and any medical bills. Accurate reporting here is essential for assistance consideration.
If you have applied for other financial assistance programs in the past year, note their status and reasons for any denials.
Finally, review all entries for accuracy before signing and dating the application. Attach required documents as specified at the end of the form.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What to do when a patient refuses to pay?

If, despite gentle reminders and special efforts to collect amounts due, a patient still refuses to cooperate, it may be time to discharge him or her.

What if you had a patient that did not pay?

If after all these efforts, the patient still doesnt pay, the physician should send the bill to collections and dismiss the patient via a certified letter, requesting a return receipt. Dr. Fuller notes that physicians should provide dismissed patients with at least one month of time to find new medical care.

How do I request financial assistance?

5 Tips for Asking for Financial Help Figure out Your Needs. Youll feel more comfortable asking for help when you have a clear picture of your needs. Ease into It. Explain the Stakes. What will happen if you dont get financial help? Have a Plan. Be Gracious.

What do you do when patients cannot pay?

Our financial assistance programs are designed to ensure you receive the care you need, regardless of your financial situation. The Financial Assistance Program applies to medically necessary services billed by OhioHealth. Exclusions include transplant-related services and elective cosmetic procedures.

What happens when someone cannot pay for healthcare services?

Once medical bills enter collections, they are often reported to consumer credit reporting companies. Medical debt collections on a credit report can impact your ability to buy or rent a home, raise the price you pay for a car or insurance, and make it more difficult to find a job.

What is the North Carolina financial Hardship Program?

Have the money conversation. Get creative with your scheduling. Offer a payment plan. Create a sliding fee scale. Accept what they can offer. See them pro bono. Refer them or help them find assistance. Barter.

What happens if a patient cant afford treatment?

If you and your patient cant agree on a fee or you have already maxed the number of low-cost clients you can afford send them to a local community hospital or clinic. Many offer low-cost or no-cost care to patients with proven financial needs.

Patient Financial Assistance Application 2025

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