Jps Verification Of Assistance Form Details

Have you ever needed to provide information to a hospital or other healthcare provider but weren't sure what was required? The Jps Health Network Verification Form can help make the process easier. This form is designed to collect all the information necessary for the hospital to verify your insurance and patient eligibility. In this blog post, we'll take a closer look at what's included on the form and how to complete it.

Here is the data concerning the file you were in search of to fill out. It can tell you how long it should take to finish jps health network verification, exactly what fields you will need to fill in and some additional specific details.

QuestionAnswer
Form NameJps Health Network Verification
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesjps how do i get jps application for insurance, jps verification of assistance form, jps printable application, jps health network employment verification form

Form Preview Example

JPS Health Network

Verification of Assistance and Residency for

JPS Connection Program

This form only needs to be completed if the applicant is being supported by another individual.

I, ___________________________________________ verify that ___________________________________________

Name of person providing assistanceApplicant’s full name

Patient’s MR# _____________________________ and/or Social Security # ____________________________________

lives at ___________________________________________________________________________________________

Applicant Address

City/Zip Code

 

Financial Assistance: I provide financial assistance to the applicant. Yes

No

This individual is claimed as a dependent on my most recent filed income tax return.

Yes No

Does the applicant have a job? _____________ If yes, provide employer name__________________________________

Does the applicant have another income source? _____________ If yes, how much

___________________________

I provide applicant with the following: Food Personal items

Transportation

Cash/Check $ _____________ per Week or Month

Other ____________________

Do you pay rent or other bills for this applicant? ____________ If yes, how much and how often? __________________

Residency Assistance:

The applicant resides at my Tarrant County residence.

They do not pay me rent.

They pay ____________ to help toward the rent and utilities.

How long has the applicant lived at your Tarrant County residence? _______________

Does the applicant have another residence? ___________ If yes, where _________________________________

Documentation Attached for Person Providing the Assistance:

Provide picture identification (example - Drivers License)

Provide proof of residence (example - utility bill, lease agreement or ownership documentation)

Relationship to Patient: ___________________________________

I certify that the above information is true and correct. "I understand that anyone who knowingly lies or misrepresents the truth or arranges for someone to knowingly lie or misrepresent the truth in the completion of this application is committing a crime which can be punished under federal law and/or state law. Everything on this application is the truth as best I know it.”

Signature - Person providing assistance: _________________________________________________

Address, City, State, Zip: _________________________________________________

Phone Number: _________________________________________________

Date signed: _________________________________________________

THIS FORM MUST BE SIGNED AND NOTARIZED.

State of Texas County of ____________________

Before me, a notary public, on this day personally appeared__________________________________, known to me to be

the person whose name is subscribed to the foregoing document and, being by me first duly sworn, declared that the statements therein contained are true and correct.

__________________________________________

Notary Public’s Signature (Personalized Seal)

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