Navigating the healthcare system can often feel overwhelming, especially when facing the prospect of steep medical bills. An essential resource for those seeking relief is the Application for Financial Assistance form, a crucial document for individuals and families grappling with the financial burdens of healthcare costs. This form serves as a bridge between patients and the necessary financial aid, detailing pertinent information like the patient's name, address, and importantly, their social security and insurance details. It queries applicants about residency status at the time of receiving hospital services in Ohio, insurance coverage specifics, and whether they were beneficiaries of Disability Assistance or Medicaid. Completing this application requires patients to provide a thorough snapshot of their personal and financial situation, including attaching proof of any insurance or assistance programs they're part of. Located at the heart of Cincinnati, Ohio, the address provided connects applicants directly with the Patient Financial Services, where dedicated professionals stand ready to process these forms. This setup underscores a commitment to making healthcare financially accessible to residents, reflecting an understanding of the diverse needs within the community.
| Question | Answer |
|---|---|
| Form Name | Application For Financial Assistance Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | christ hospital financial assistance, nancialassistance, christ hospital financial aid, the christ hospital financial assistance form |
PLEASE PRINT
Today's Date:
Patient Name:
Responsible Party, if not Patient
Patient Address:
PATIENT FINANCIAL SERVICES
2139 AUBURN AVE.
CINCINNATI, OHIO 45219
(513)
Application for Financial Assistance
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Patient Date of Birth: |
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Date of Hospital Services: |
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Were you an Ohio resident at the time of your hospital services?
Did you have health insurance at the time of your hospital services?
Were you an active recipient of Disability Assistance or Medicaid at the time of
Yes
Yes
Yes
No
No
No
*If you answered "Yes" to any question, please attach a copy of your insurance card (front
and back?, Medicaid, or Disability Assistance card to this application and complete the following:
Name of Insurance Company
Policy #
Insurance Phone #
Group #
Medicaid or Disability Assistance Number