Robert Wood Johnson Hospital Letterhead – Fill Out and Use This PDF

OFFICE HOURS: (732) 418-8450 – HOURS: 9:00 AM – 4:30 PM NO APPOINTMENT REQUIRED

ROBERT WOOD JOHNSON UNIVERSITY HOSPITAL

120 ALBANY ST

6TH FLOOR, TOWER TWO

NEW BRUNSWICK, NJ 08901

charity.care@rwjuh.edu

THE REQUESTED INFORMATION BELOW MUST BE PROVIDED AT THE TIME OF YOUR INTERVIEW WITH A FINANCIAL COUNSELOR.

***ADDITIONAL INFORMATION MAY BE REQUESTED AFTER THE APPLICATION IS REVIEWED. ***

***PLEASE NOTE THAT ANY AND ALL INFORMATION BEING PRINTED FROM THE INTERNET, MUST BE VERIFIED BY A SIGNATURE AND STAMP FROM THAT COMPANY.***

PROPER IDENTIFICATION (SUPPLY ONE OF THE FOLLOWING FOR EACH FAMILY MEMBER) *** If you are a full time college student 21 yrs or younger you must provide all documents for both parents as well. They will be included in your family size as well as any sibling who is a full time student 21 yrs or younger ***

PROOF OF NEW JERSEY RESIDENCY: (FOR THE MONTH OF YOUR REQUESTED SERVICE). You must supply one of the below required documents.

INCOME:

Actual gross income for the month immediately preceding the date of service or three month’s income immediately preceding service:

a)Pay stubs, unemployment stubs, disability, child support.

b)A letter from employer(s) on company letterhead (INCLUDING Name, Address and Telephone number) – Letter must state the Gross Income, also needs to state if covered by health insurance.

c)Copy of social security and/or pension award letter.

d)If not employed and have no income, must supply a letter from person supporting you.

e)If you receive financial aid for schooling you must supply the financial aid award letter for your last 2 semesters immediately preceding your date of service.

LIQUID ASSETS:

You must provide copies of any checking and savings accounts, IRA’s, CD’s, stocks and/or bonds, or any other account which can be readily converted into cash. All account statements must be valid for the date of service in question.

MEDICAID ELIGIBILITY:

If you are a under the age of 18, over the age of 65, Blind or Disabled or pregnant- You must show proof that you were screened for eligible Medicaid programs.

COPY OF ALL PAGES YOUR COMPLETED TAXES AND W2 FOR THE PRIOR YEAR

COPIES OF ANY AND ALL INSURANCE CARDS FOR EACH FAMILY MEMBER

Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732) 418-8450

Date:

To Whom It May Concern:

This is to state that I ________________________________________ do NOT have the

following (please check off what you do NOT have):

__________ 1040 Income Tax (Federal) Year

Did Not File

Do not work, collect unemployment, disability or receive financial assistance.

Checking Account

Savings Account

CD’S/STOCKS/ I.R.A. PLANS/ 401K

Medical/Dental/No Fault Insurance

_________________________________________________

Signature

Additional Comments:

Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732) 418-8450

Date:

To Whom It May Concern:

This is to state that I ________________________________________ do NOT have the

following (please check off what you do NOT have):

__________ 1040 Income Tax (Federal) Year

Did Not File

Do not work, collect unemployment, disability or receive financial assistance.

Checking Account

Savings Account

CD’S/STOCKS/ I.R.A. PLANS/ 401K

Medical/Dental/No Fault Insurance

_________________________________________________

Signature

Additional Comments:

Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732) 418-8450

To Whom It May Concern:

I, the undersigned, ________________________________________ (relation to patient)

______________________________, provide the necessary room, board and other life essentials for

_____________________________________________________________ at my residence,

___________________________________________________________, and have been doing so from

___________________________ to ________________________________.

I am not responsible or able to pay for any hospital or other medical expenses for him/her.

_________________________________________________ ________________________

Signature

Date

Telephone #: (_____) ________________________

Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732) 418-8450

Date: __________________________________

I__________________________________________ state that I am not married to my

son’s/daughter’s/children’s father and receive no financial support from him although he provides us with food and shelter.

Signature

I__________________________________________ state that I am not married to my

son’s/daughter’s/children’s father and receive no financial support for him/her/them.

Signature

I__________________________________________ state that I am not married to my

son’s/daughter’s/children’s father but I do receive financial support for him/her/them.

Signature

Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732) 418-8450

Date of initial separation:

Legal residence of applicant:

Legal residence of spouse:

I, _____________________________________________, certify and attest to the truthfulness of the

following:

1.That my spouse and I are separated and no longer reside together.

2.That I have no access to the funds of my spouse.

3.That I receive no support or monies from my spouse.

4.That my spouse and I have no financial ties.

5.That my spouse and I do not mingle or join our funds in any way, including the filing of joint federal or state income tax returns.

Signature:Date:

Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732) 418-8450

APPLICATION FOR FINANCIAL ASSISTANCE

I understand that the information which I submit is subject to verification by the appropriate health care facility and the Federal or State Governments. Willful misrepresentation of these facts will make me liable for all hospital charges and subject to civil penalties.

If so requested by the health care facility, I will apply for governmental or private medical assistance for payment of the hospital bill.

I certify that the above information regarding my family size, income and assets is true and correct.

I hereby certify that the information provided for purpose of creating a financial assistance/Charity Care application is correct to the best of my knowledge.

I understand that it is my responsibility to advise the hospital of any change in status in regards to my income or assets.

PROVIDER NAME: Robert Wood Johnson University Hospital

Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732) 418-8450