Caring Hearts Program Form PDF Details

Finding financial aid for medical services when faced with financial challenges can be a daunting process. The Caring Hearts Financial Assistance Application offered by ThedaCare provides a beacon of hope for patients unable to afford medically necessary services carried out by its various divisions. This comprehensive program, which acts as a safety net for those in need, requires applicants to complete an application and provide all necessary supporting documentation to ensure consideration. ThedaCare's commitment to supporting patients with financial need is evident through the establishment of clear eligibility guidelines, emphasizing the program as a last resort after exploring other payment sources. It is crucial to note, however, that the program specifically excludes elective services, services provided by non-ThedaCare providers, and services already compensated directly to patients or pending payment from third-party liabilities. To facilitate access to the program and its details, ThedaCare has made information readily available online, through customer support, and at various ThedaCare facilities. Prompt submission of the application and supporting documents is vital, as ThedaCare continues collection efforts on unpaid balances if these are not provided within a specified timeframe. Understanding the conditions, covered services, and the application process can significantly impact the financial burdens faced by qualifying patients seeking essential medical care.

QuestionAnswer
Form NameCaring Hearts Program Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesthedacare financial, caring hearts assistance, caring hearts program, caring hearts thedacare

Form Preview Example

Enclosed please find a Caring Hearts Financial Assistance Application. Please complete the entire application and submit all requested supporting documentation to avoid denial of your application.

Caring Hearts is a financial assistance program designed for patients who are unable to pay for medically necessary services provided by all divisions within ThedaCare. ThedaCare has established eligibility guidelines for our Caring Hearts Program based on financial need and is considered to be the last resort after all other payment sources have paid.

The Caring Hearts Program covers services which are deemed to be medically necessary as determined by your physician.

The Caring Hearts Program does not cover:

Elective Services - cosmetic, bariatric, as well as other non-medically necessary services

Non ThedaCare providers – examples include radiologists, pathologists, anesthesiologists,

independent surgeons, and independent physicians. A complete list of covered and non- covered providers can be found in the document titled “List of Providers that are covered/not covered by Caring Hearts”.

Dates of Service that were paid directly to you by the insurance company.

Dates of Service pending third party liability payment.

You may obtain a copy of the ThedaCare Caring Hearts Financial Assistance Policy or the list of covered and non-covered providers by:

1.Visiting our web site at www.thedacare.org/PaymentOptions.

2.Contacting our Customer Support Department at 1-800-236-4102.

3.Mailing a request in writing to: ThedaCare Billing PO Box 8003 Appleton, WI 54912

4.Visit a Patient Billing Services Office at one of the following locations. For the privacy of all patients, please present to registration during the hours of 8:30 4:30. They will connect you with a customer support team member.

ThedaCare Regional Medical Center - Appleton - 1818 N. Meade St., Appleton, WI

ThedaCare Medical Center - Berlin 225 N. Memorial St, Berlin, WI

ThedaCare Medical Center Shawano - 100 County Road B, Shawano, WI

ThedaCare may continue collection efforts of unpaid balances if a complete application along

with all requested supporting documentation is not returned within 30 days. A letter stating your acceptance or exclusion from the Caring Hearts Program will be sent after your completed application has been processed.

If you have any questions or need assistance in completing the application, please call our customer support department at 920-830-5900, or toll free at 800-236-4102.

Sincerely,

ThedaCare Customer Support Department

 

Caring Hearts Application

Date:__________________

Account Number:_________________________

Name of responsible party: _________________________________________Birth Date: _______________

Name of Spouse:

 

 

Birth Date: ________________

 

First

Last

Address: ___________________________________City/State: _____________________Zip: ___________

Phone Number:

Home: _______________________ Cell: _______________________

Marital Status (Please Circle): Married Single

Widowed Separated

Divorced Life Partner

List all dependents in your household:

 

 

 

 

Name

 

Date of Birth

 

Relationship to You

 

Dependent on your most recent

 

 

 

 

 

 

Federal Tax Return?

 

 

 

 

 

 

Y / N

 

 

 

 

 

 

 

 

 

 

 

 

 

Y / N

 

 

 

 

 

 

 

 

 

 

 

 

 

Y / N

 

 

 

 

 

 

 

 

 

 

 

 

 

Y / N

 

 

 

 

 

 

 

 

 

 

 

 

 

Y / N

 

 

 

 

 

 

 

 

 

 

 

 

 

Y / N

 

 

 

 

 

 

 

Are there any open claims for workman's compensation, motor vehicle accidents, or third party liability that may pay on dates of service related to this request for financial assistance? __Yes __No

If yes, date of Incident: ____________________

Are you participating in a cost share program? __Yes __ No

Is there anyone in the household currently without health insurance? __Yes __ No

If yes, please list who: ____________________________________________________________________

Income: Please list all income below received monthly by all members of the household. This includes: employment, self-employment, unemployment, social security, disability, VA benefits, pension, retirement, monthly annuity payments, etc.

Recipient’s Name

Source of Income

Start Date

Monthly Amount

If you have no source of income, how have you been supporting yourself?

________________________________________________________________________________________

________________________________________________________________________________________

Signature of person supporting you:

 

 

 

Print Name:___________________________

Relationship:

 

 

 

Can we discuss this application with the above? Y / N

Please list all open checking and savings account(s) for all household members below:

 

Account Owner

Type of Account

Bank Name

 

Estimated Balance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I certify that the above information is true and accurate to the best of my knowledge. Further, I will take action to apply for any assistance (Medicaid, Medicare, insurance, etc.), which may be applicable for payment of my hospital/physician charges, and I will take any action reasonably necessary to obtain such assistance. I will assign or pay to ThedaCare the amount recovered for charges. I authorize ThedaCare to verify any and all information presented in this application including but not limited to: employment verification and bank verification. I understand that any false or misleading information will void this application and exclude me from financial assistance. I understand that ThedaCare will scan and retain all financial assistance applications and financial documentation in accordance with its internal and external compliance requirements.

Date of Request: ____________________________

Applicant’s Signature: _____________________________________________________

Required Financial Documentation – PLEASE READ CAREFULLY

Please read the scenarios below and proceed to the appropriate section on pages 3 and 4 based on your tax filing status. You only need to complete the one section that best fits your situation.

The financial documentation must be submitted with your application.

Are you required to file taxes by the Federal Government? Please check one of the following:

If Yes and your financial situation has not changed since filing: Proceed to Section A

If No: Proceed to Section B

If Yes and self-employed: Proceed to Section C

If Yes and your financial situation has changed since filing: Proceed to Section D

Section A: Required to File Taxes and Your Financial Situation Has Not Changed Since Filing

Please include the following information:

For all bank accounts listed above, please include the full, detailed statement for the most recent month. Statements need to include financial institute name, account holder name, account number(s) and need to include all pages.

Please submit a copy of your most recent Federal Tax Return. To request a copy of your taxes if needed, please call 1-800-829-1040.

Completed and signed Caring Hearts Application.

Written approval/denial response from Medical Assistance if any of the following apply:

-If you have children under the age of 18 -If you are currently pregnant

-If you have been determined disabled -If you are over the age of 65

-If you are a Wisconsin immigrant with a medical emergency -If you are childless adult within Federal Poverty Guidelines

Contact the Department of Health and Human Services in the county that you reside in or access their website at (https://access.wisconsin.gov/access/) for assistance.

Section B: Not Required to File Taxes

Please include the following information with your application:

For all bank accounts listed above, please include the full, detailed statement for the most recent month. Statements need to include financial institute name, account holder name, account number(s) and need to include all pages.

2 most recent payroll statements or proof of income received

Completed and signed Caring Hearts Application.

Written approval/denial response from Medical Assistance if any of the following apply:

-If you have children under the age of 18 -If you are currently pregnant

-If you have been determined disabled -If you are over the age of 65

-If you are a Wisconsin immigrant with a medical emergency -If you are childless adult within Federal Poverty Guidelines

Contact the Department of Health and Human Services in the county that you reside in or access their website at (https://access.wisconsin.gov/access/) for assistance.

Section C: Self-Employed

Please include the following information with your application:

Please submit a copy of your most recent Federal Tax Return. To request a copy of your taxes if needed, please call 1-800-829-1040.

For all bank accounts listed above, please include the full, detailed statement for the most recent month. Statements need to include financial institute name, account holder name, account number(s) and need to include all pages.

Completed and signed Caring Hearts Application.

Written approval/denial response from Medical Assistance. Contact the Department of Health and Human Services in the county that you reside in or access their website at (https://access.wisconsin.gov/access/) for assistance.

Section D: Required to File Taxes and Your Financial Situation Has Changed Since Filing

Please include the following information with your application:

Please submit a copy of your most recent Federal Tax Return. To request a copy of your taxes if needed, please call 1-800-829-1040.

For all bank accounts listed above, please include the full, detailed statement for the most recent month. Statements need to include financial institute name, account holder name, account number(s) and need to include all pages.

2 most recent payroll statements or proof of income received

Completed and signed Caring Hearts Application.

Written approval/denial response from Medical Assistance if any of the following apply:

-If you have children under the age of 18 -If you are currently pregnant

-If you have been determined disabled -If you are over the age of 65

-If you are a Wisconsin immigrant with a medical emergency -If you are childless adult within Federal Poverty Guidelines

Contact the Department of Health and Human Services in the county that you reside in or access their website at (https://access.wisconsin.gov/access/) for assistance.

Financial Changes

Please describe any financial changes that have occurred since the completion of most recent Federal Tax Return. Please attach any additional documentation or verification of the financial changes noted below.

Describe Change:

Previous

Current

___________________________________________________

$__________

$__________

___________________________________________________

$__________

$__________

___________________________________________________

$__________

$__________

___________________________________________________

$__________

$__________

___________________________________________________

$__________

$__________

How to Edit Caring Hearts Program Form Online for Free

Using PDF documents online is actually very easy with this PDF tool. You can fill in thedacare financial assistance here with no trouble. FormsPal expert team is constantly working to develop the tool and insure that it is even easier for people with its many features. Unlock an constantly innovative experience now - take a look at and find out new possibilities along the way! With a few simple steps, you may begin your PDF editing:

Step 1: Press the orange "Get Form" button above. It will open up our editor so that you can start filling out your form.

Step 2: This tool provides the ability to modify your PDF form in a range of ways. Enhance it by including any text, adjust original content, and add a signature - all within the reach of a couple of clicks!

As for the blank fields of this precise PDF, here's what you need to do:

1. Whenever filling in the thedacare financial assistance, ensure to include all of the essential fields in their associated section. This will help to expedite the process, making it possible for your details to be processed promptly and correctly.

Completing segment 1 of thedacare caring

2. Once your current task is complete, take the next step – fill out all of these fields - Y N Y N Y N Y N Y N Y N, Are there any open claims for, Recipients Name, Source of Income, Start Date, and Monthly Amount with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

thedacare caring completion process shown (part 2)

3. Through this part, examine If you have no source of income, Account Owner, Type of Account, Bank Name, Estimated Balance, and I certify that the above. Every one of these are required to be taken care of with greatest accuracy.

Completing section 3 in thedacare caring

4. This next section requires some additional information. Ensure you complete all the necessary fields - I certify that the above, and If Yes and your financial - to proceed further in your process!

Completing segment 4 in thedacare caring

When it comes to If Yes and your financial and I certify that the above, ensure that you take another look here. The two of these are surely the most significant ones in this page.

5. This document has to be concluded with this particular section. Here you have an extensive list of blanks that require correct information for your document submission to be accomplished: Section A Required to File Taxes, For all bank accounts listed, month Statements need to include, needed please call, Please submit a copy of your most, If you have children under the age, Contact the Department of Health, and Section B Not Required to File.

Contact the Department of Health, Section B Not Required to File, and needed please call of thedacare caring

Step 3: Just after taking one more look at your form fields, click "Done" and you're done and dusted! Go for a 7-day free trial option at FormsPal and obtain direct access to thedacare financial assistance - which you are able to then use as you want inside your FormsPal cabinet. Here at FormsPal.com, we aim to ensure that all of your details are maintained private.