Navigating the financial landscape of healthcare can often feel overwhelming, especially in the face of necessary but potentially costly medical services. Recognizing this challenge, the Promedica Financial Assistance form emerges as a critical tool designed to alleviate some of these financial burdens for eligible patients and their families. The form provides a comprehensive and structured approach to apply for financial assistance, requiring applicants to diligently fill out various sections and provide detailed proof of income. This encompasses a broad range of documentation including wage verification, unemployment information, Social Security award letters, and more, aiming to paint a full picture of the applicant's financial situation. Specifically tailored for residents and certain criteria such as family size and income thresholds play a decisive role in the determination of eligibility for free or discounted care, even for those already insured. Importantly, the form also serves as a means to ensure confidentiality and a straightforward process for patients to follow, underlined by the necessity for honest and accurate reporting of information to avoid legal repercussions. Such an initiative not only underscores Promedica's commitment to accessibility of care but also to fostering trust and transparency within the patient-provider relationship.
| Question | Answer |
|---|---|
| Form Name | Promedica Financial Assistance Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | promedica financial application, promedica authorization form, promedica financial assistance form, promedica financial assistance application |
Financial Assistance Application
Directions for completing application
Please complete all of the fields on this application and sign the application where indicated. Please provide all types of gross family income as indicated below. Proof of your income should also be provided. Types of proof include wage verification (pay stubs 1 year prior to the date of service you are requesting assistance for), unemployment information, Social Security award letters,
Please note all information provided is confidential and is only used for the purpose of determining your discount.
If your family income after January 22, 2014 is within the income ranges below, you may be eligible to receive free care for necessary medical services even if you have insurance.
If you do not have insurance and your family income after January 22, 2014 is within the ranges below, you may be eligible for discounted care.
Family Size |
Annual Income |
1 |
$23,340 |
2 |
$31,460 |
3 |
$39,580 |
4 |
$47,700 |
5 |
$55,820 |
6 |
$63,940 |
7 |
$72,060 |
8 |
$80,180 |
For each additional person add: |
$8,120 |
Family Size |
Annual Income |
1 |
$46,680 |
2 |
$62,920 |
3 |
$79,160 |
4 |
$95,400 |
5 |
$111,640 |
6 |
$127,880 |
7 |
$144,120 |
8 |
$160,360 |
For each additional person add: |
$16,240 |
Today’s Date: ___________________ Visit/Account # _______________________
Patient Name: _________________________________________ Last 4 Digits of Patient Social Security # _______
Patient address: ________________________________________________________________________________
Home Phone # _______________________ Cell Phone # _______________________
City: _______________________________ State: ________ Zip code: ___________
Please provide your email address if you would like to receive communication regarding this application via email:
___________________________________________________
Patient date of birth: _____/_____/____ |
Marital Status: |
S M W D |
Gender: M F |
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What county do you live in? ______________________ |
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Have you been a resident of that county for the past 6 months? |
Yes |
No |
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Are you a citizen of the United States? |
Yes |
No |
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Were you an Ohio resident at the time of your service? |
Yes |
No |
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Please provide the following information for all of the people in your immediate family that live in your home. For the purposes of this application, “family” is defined as the patient, patient’s spouse and natural or adopted children under the age of 18 who live in the patient’s home. If patient is under 18, please include parent’s income.
If there is no income, please explain how patient is supporting self: ___________________________________________
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Gross Income |
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3 Months Prior to |
Gross Income 12 |
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Relationship |
Date |
Months Prior to |
Current Gross |
Type of |
Name |
Age |
to Patient |
of Service |
Date of Service |
Monthly Income |
Income |
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TOTALS:
Patient/Guarantor employer for the last 12 months:
Name of employer: _______________________________________________ Date hired: _____ Date Ended: _______
Name of employer: _______________________________________________ Date hired: _____ Date Ended: _______
Spouse’s employer for the last 12 months:
Name of employer: _______________________________________________ Date hired: _____ Date Ended: _______
Name of employer: _______________________________________________ Date hired: _____ Date Ended: _______
Have you applied for Medicaid? Yes No |
If yes, what were the results? _________________________________ |
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If you were denied by Medicaid, why? _________________________________________ |
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Have you applied for Social Security disability assistance? |
Yes No |
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If yes, what were the results? Approved |
Denied |
If approved effective date: __________ |
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Do you have health insurance other than Medicaid? |
Yes |
No |
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Do you have auto insurance if service is auto related? Yes No If yes, please list information below:
Name of Insurance: _________________________ Policy # ______________ Group# ____
Address of Insurance: ______________________ Phone # _______________________
I understand any financial assistance provided may be reversed if it is determined this information is not correct. “Providing false information to induce another to extend credit or to bestow any other valuable benefit may be a violation of the Ohio Revised Code Section 2921.13.”
By signing below, I state the information on this application is true to the best of my knowledge.
______________________________ |
_________________ |
Signature of patient/guarantor |
Date/Time |
______________________________ |
___________________ |
Signature of spouse |
Date/Time |
______________________________ |
___________________ |
Signature of staff member (if applicable) |
Date/Time |
If you have questions, please contact us at
Mail the completed application to: CBO, Attention Financial Assistance, 2142 N. Cove Blvd, Toledo, OH 43606.
Application can be faxed to:
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