The financial assistance form is a document that can be used to request financial aid from a variety of sources, including the government and private organizations. The form can be used for a wide range of purposes, including paying for college tuition, housing costs, and other expenses. When filling out the form, it is important to provide accurate and complete information. Be sure to include your name, contact information, and the reason you are requesting financial assistance. Make sure to submit the form as soon as possible so that you can receive the help you need.
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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M.I. |
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M.I. |
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Home Phone #: |
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Home Phone #: |
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Patient Social Security Number: |
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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