Ahca Form 5220 0001 PDF Details

In the complex landscape of health care assistance within Florida, the AHCA 5220 0001 form emerges as a critical document for those seeking financial aid for medical services. This comprehensive form, issued by the State of Florida's Agency for Health Care Administration, serves as an initial application for health care assistance, geared primarily towards residents facing financial difficulties. The form is meticulously structured into several parts, starting with gathering household information directly from the applicant, which encompasses personal identification details, living situation, insurance coverage, and any applicable health conditions such as blindness, disability, or pregnancy. Financial information forms the second part, requiring applicants to disclose incomes and assets, aiming to paint a comprehensive picture of the applicant's financial standing. The declaration section follows, mandating an assurance of truthfulness and compliance from the applicant, accentuating the legal implications of providing false information. Balancing between providing care and ensuring eligibility, the form also entails sections to be filled out by hospital personnel, which document patient admission details and any referrals made, ensuring a holistic approach to each case. This methodical process, underlined by the requirement for authenticity and thorough documentation, underscores Florida’s dedication to offering targeted assistance while maintaining program integrity, ensuring only those truly in need receive support.

QuestionAnswer
Form NameAhca Form 5220 0001
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesacha form 5220, hcra florida, YYYY, AHCA

Form Preview Example

SCS

HCRA

State of Florida, Agency for Health Care Administration

In-County ____

Applicant's County

HEALTH CARE ASSISTANCE APPLICATION

Out-of-County ___

of Residence

PART 1 - HOUSEHOLD INFORMATION - To Be Completed By Applicant

 

 

 

 

 

 

 

 

Health Insurance or

 

 

 

 

 

 

 

 

 

 

 

Agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

First, Middle,

Last

 

Social Security Number

 

Date of Birth

Relationship to Applicant

3rd Party Coverage

Blind

 

Disabled

 

Pregnant

 

Referred To

 

 

 

 

 

 

 

 

 

 

 

 

P A T I E N T

Yes

No

Yes

No

 

Yes

 

 

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

Yes

 

 

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

Yes

 

 

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

Yes

 

 

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

Yes

 

 

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

Yes

 

 

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

Yes

 

 

No

 

Yes

No

 

 

Living Address:

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

Previously

Hospitalized

in Florid

a

 

 

If yes,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

in Last Year?

 

Yes

 

 

No

Where:

 

 

 

Phone

 

 

 

Shelter

 

 

Rent

Buy

Own

Other

 

U.S. Citizen?

 

 

 

 

Alien Regisgration

 

 

 

 

Number:

 

 

 

Situation:

 

 

 

Yes

No

 

 

No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART 2- FINANCIAL INFORMATION - To Be Completed By Applicant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INCOME

 

 

 

 

 

GROSS

 

 

 

 

 

 

 

ASSETS

 

 

 

 

 

 

 

EXAMPLES

 

TYPE

 

 

WHO HAS

 

AMOUNT

 

HOW OFTEN

 

EXAMPLES

 

 

TYPE

 

WHO HAS

 

VALUE

Wages, Self-Employment,

 

 

 

 

 

 

 

 

 

$

 

 

Cash, Checking account, Car/truck,

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security, Child Support

 

 

 

 

 

 

 

 

 

$

 

 

Motorcycle, Burial insurance, Trust

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contributions, Unemployment

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

Compensation, Railroad

 

 

 

 

 

 

 

 

 

$

 

 

funds, Life insurance, Burial plot,

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Retirement, SSI, AFDC

 

 

 

 

 

 

 

 

 

$

 

 

Real estate, Business equipment,

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

TOTAL INCOME

$

 

 

Boat, Stocks/Bonds, Savings

 

 

 

 

 

TOTAL ASSETS

$

 

 

PART 3 - DECLARATION

I am applying for assistance. I understand that I will have to give true information on this form. It could be a crime if I am not truthful about my eligibility for assistance.

I agree to turn in papers that are required to show that I am eligible, except for papers I cannot get through no fault of my own. If I cannot get papers, I agree to give the names of persons or places that may be contacted for the required information I agree to apply for any other medical assistance program I may be eligible for.

I agree that the Agency for Health Care Administration or the county may verify the information I give on this form and at my interview. I agree that they may contact my present or past employers, if it relates to my eligibility. I agree that they can get information that affects my eligibility from any records.

 

 

Signature

 

 

 

Date

 

 

 

 

 

 

Spouse's or Representative's Signature

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART 4- PATIENT INFORMATION - To Be Completed by Hospital Personne

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Admitted or

Date of

 

 

Patient

 

 

 

 

 

 

 

 

 

 

 

 

Services Provided:

Discharge:

 

 

Account No.:

 

 

 

 

Deceased: Yes

No

Date:

 

 

 

Case Mgmt.

 

 

Enrolled

 

 

 

Previously Hospitalized in

this

hospital

 

 

 

If yes,

 

InPatient:

# Days

Agency:

 

 

Referred

Date:

 

 

in Last Year?

 

 

 

Yes

 

 

No

When:

 

OutPatient

$

Total Charge

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART 5 - REFERRAL HOSPITAL - To Be Completed By Hospital Personne

 

 

 

 

 

 

 

 

 

 

 

Hospital

 

Referral Hospital:

 

 

 

 

 

 

 

 

 

HCRA ID #:

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Sent To

 

Address:

 

 

 

 

 

 

 

 

 

 

 

County:

 

 

Signature:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

 

Print Name:

 

 

 

 

 

 

Number:

 

 

 

Charity Obligation Met?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

PART 6 - COUNTY/AGENCY USE

WORKER:

 

DATE

Name

 

 

STAMP

Phone Number

 

Application Approved:

 

Yes No

 

AHCA Form 5220-0001 December 1998/HCRA

AHCA Form 5220-0001 December 1998/HCRA

When entering a date - Please use the MM/DD/YYYY format, example: 06/15/1961.

When entering dollar amounts - do not use a comma.

INSTRUCTIONS TO PATIENT/APPLICANT

Use the tab key to navigate the form.

We would like you to fill out as much of Part 1 and Part 2on the front as you can. If you cannot fill it out, a hospital worker will help you. In Part 1, list your name first and then list the names of all relatives that live with you.

DO NOT write in Parts 4, 5, and 6. These are for office use only. DO NOT write on the back of this form.

In order for this form to count as an application for assistance in paying your hospital bill, you must read, sign and date Part 3 on the front. Be sure to fill in your address so we can contact you about an interview should we need to request additional information.

Return ALL COPIES of this form to a hospital staff person.

INSTRUCTIONS TO HOSPITAL WORKER

Complete Part 1 and Part 2 for the patient/applicant unless the patient/applicant wants to do it.

Assist the patient/applicant in obtaining all necessary vertifications.

Give the YELLOW copy of the form to the patient/applicant.

Complete Part 4 and Part 5. Sign Part 3 if the patient is unable to sign or if the hospital is acting as the patient's representative. Send the WHITE copy to the certifying agency for processing with all verification obtained.

Retain the PINK copy for your records.

INSTRUCTIONS TO CERTIFYING AGENCY

Date stamp in Part 6 upon receipt.

Determine whether all necessary verification has been provided.

Schedule an interview with the patient/applicant to obtain additional information if necessary.

Determine eligibility.

Notify patient/applicant and referring hospital of decision.

AHCA Form 5220-0001 December 1998/HCRA

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Florida completion process explained (step 1)

2. Now that the last array of fields is done, you should add the needed details in TOTAL INCOME, Boat StocksBonds Savings, TOTAL ASSETS , PART DECLARATION I am applying, Signature, Date, Spouses or Representatives, Date, PART PATIENT INFORMATION To Be, Date of Discharge, Patient Account No, Case Mgmt, Agency, Enrolled Referred, and Date in order to move on to the 3rd step.

Spouses or Representatives, Agency, and Date in Florida

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