Caring Hearts Program Form – Fill Out and Use This PDF

Caring Hearts Program Form PDF Details

The ThedaCare Caring Hearts Financial Assistance Application helps patients who cannot afford medically necessary care at ThedaCare facilities. This financial assistance application acts as a safety net for patients facing serious financial hardship, covering a broad range of medical services when all other payment sources have been explored first.

Eligibility for the Caring Hearts Financial Assistance Program

To qualify, applicants must demonstrate financial need based on household income and assets. ThedaCare evaluates eligibility using Federal Poverty Level guidelines. Patients with any insurance coverage may still qualify if their out-of-pocket costs create a financial hardship. The program is a last-resort option, meaning applicants must first exhaust other resources including Medicaid, Medicare, and any third-party liability coverage before the caring hearts financial assistance is applied.

Key requirements include:

• Proof of income for all household members, including start date and monthly amount for each source
• Current bank account statements for all accounts held by the applicant
• Documentation showing that other forms of assistance and payment sources have been pursued
• Completed application submitted promptly, along with all required supporting documents

What the Program Covers and What It Excludes

The Caring Hearts Program covers medically necessary services provided by ThedaCare and its affiliated divisions. Common covered services include emergency care, inpatient treatment, outpatient procedures, and diagnostic testing ordered by a ThedaCare provider.

Patients should be aware of several exclusions. Elective procedures that are not deemed medically necessary are not covered. Services provided by non-ThedaCare providers are also excluded, even if received at a ThedaCare location. Additionally, services for which payment has already been made directly to the patient or is pending from a liability claim are not eligible.

How to Complete and Submit Your Application

The caring hearts application collects detailed financial information in multiple sections. Work through each section carefully to avoid delays in processing:

• Patient identification: Provide your full name, address, contact details, and date of service
• Income information: List every source of household income, the start date, and the monthly amount received
• Asset documentation: Disclose all bank accounts by providing the account owner name, account type, bank name, and estimated balance
• Certification and signature: Certify that all information provided is accurate and complete before submitting

ThedaCare continues collection efforts on unpaid balances until a completed application is received and reviewed. Submitting your caring hearts financial assistance application quickly, with all supporting documents included, helps pause collection activity while your case is under review. Submit your application online, in person at any ThedaCare facility, or by contacting ThedaCare customer support directly.

Supporting Documents Required

Along with the completed application form, gather the following documents before submitting:

• Recent pay stubs or income verification for all household members
• Federal tax returns if you are required to file taxes
• Monthly bank statements for all accounts
• Documentation of any additional income, benefits, or assistance received
• A written statement explaining your circumstances if you have no source of income

Frequently Asked Questions About the Caring Hearts Program

Who is eligible to apply for this financial assistance?

Any patient who has received medically necessary services at a ThedaCare facility and is unable to pay their balance may apply. The program is available regardless of insurance status, as long as the applicant can demonstrate financial hardship and has pursued other payment sources first.

What happens if the application is incomplete?

An incomplete caring hearts application may be returned, and ThedaCare may continue its collection process during that time. Attaching all required documents when you submit helps avoid delays and keeps your account in review status.

Can I apply if I already have health insurance?

Yes. Having insurance does not automatically disqualify you. If your insurance does not cover all costs and the remaining balance creates a financial hardship, you may still qualify for assistance. ThedaCare reviews each case based on total income, assets, and out-of-pocket costs.

Are there other similar medical financial assistance forms available?

Yes. Patients seeking financial assistance from other healthcare providers can review similar documents, including the Financial Assistance Application, the Cleveland Clinic Financial Assistance Form, the UVA Financial Assistance Form, and the WellStar Financial Assistance Application.