Charity Care Robert Wood Johnson Details

In the business world, first impressions are very important. This is especially true when it comes to official letters and documents. A professional and polished letterhead can make all the difference in how your correspondence is received. If you're looking for a high-quality hospital letterhead form, look no further than Robert Wood Johnson Hospital. Our letterhead is designed to provide an unmistakable air of professionalism and authority. Plus, our easy-to-use design ensures that you'll be able to create polished letters with ease.

Here is some specifics that will help you find out how much time it can take to finalize the robert wood johnson hospital letterhead.

QuestionAnswer
Form NameRobert Wood Johnson Hospital Letterhead
Form Length9 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 15 sec
Other namescharity care robert wood johnson nj, 181 somerset st new brunswick charity care, charity care robert wood johnson, robert wood johnson hospital charity care

Form Preview Example

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 ***

1. Driver’s License

2. Social Security Card

3. Valid Passport

4. Birth Certificate

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

1. Utility Bill

2. Copy of Lease or Deed

3. Driver’s License

4. Letter from individual stating that you live with

 

 

 

him/her

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

New Jersey Hospital Care Assistant Program

APPLICATION FOR PARTICIPATION

PROOF OF IDENTIFICATION, PROOF OF INCOME AND PROOF OF ASSETS MUST ACCOMPANY THIS APPLICATION

SEND COPIES OF ALL REQUESTED DOCUMENTS; DO NOT SEND ORIGINAL DOCUMENTS AS THEY WILL NOT BE RETURNED.

SECTION I – Personal Information

1.

PATIENT NAME

 

 

 

 

 

2.

SOCIAL SECURITY NUMBER

 

________________________________________ ________________________________________

 

____ ____ ____ - ____ ____ - ____ ____ ____ _____

(Last)

 

 

(First)

 

(M)

 

 

 

 

 

 

 

 

 

 

 

3.

DATE OF APPLICATION

 

4. INITIAL DATE OF SERVICE

 

5. REQUESTED DATE OF SERVICE

 

__________/__________/__________

__________/__________/__________

 

__________/__________/__________

 

Month

Day

Year

Month

Day

Year

 

Month

Day

Year

 

 

 

 

 

 

 

 

6.

STREET ADDRESS OF PATIENT

 

 

 

7.

TELEPHONE NUMBER

 

8. CITY, STATE, ZIP CODE

9. FAMILY SIZE *

10. U.S. CITIZENSHIP

Yes

No

Pending Application

11. PROOF OF 3-MONTH RESIDENCY IN THE STATE OF NJ

Yes

No

12. NAME OF GUARANTOR (If other than patient)

SECTION II – Assets Criteria

13.Individual Assets:

14.Family Assets:

15.Assets Include:

A.Cash

B.Savings Accounts

C.Checking Accounts

D.Certificates of Deposit/I.R.A.

E.Equity in Real Estate (other than primary residence)

F.Other Assets (Treasury Bills, Negotiable Paper, Corporate Stocks and Bonds)

G.Total

*Family size includes, self, spouse, and any minor children. A pregnant woman is counted as two family members.

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

SECTION III – Income Criteria

When determining eligibility for hospital care assistance, a spouse’s income and assets must be used for an adult; parent’s(s) income and assets must be used for a minor child. Proof of income must accompany this application. Income is based on the calculation of either twelve months, three months or one month of income prior to the date of service.

Patient/Family Gross Income equals the lesser of the following:

LAST 12 MONTHS

 

LAST 3 MONTHS

 

 

X 4

 

or

 

 

 

 

 

 

16.SOURCES OF INCOME:

A.Cash

B.Public Assistance

C.Social Security Benefits

D.Unemployment & Workmen’s Compensation

E.Veteran’s Benefit

F.Alimony/Child Support

G.Other Monetary Support

H.Pension Payments

I.Insurance or Annuity Payments

J.Dividends/Interest

K.Rental Income

L.Net Business Income (self employed/ verified by independent source)

M.Other (strike benefits, training stipends, military family allotment, income from estates and trusts).

N.Total

LAST 1 MONTH

X 12

or

WEEKLY

MONTHLY

YEARLY

SECTION IV – Certification by Applicant

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

17. SIGNATURE OF PATIENT OR GUARANTOR

18. DATE

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.

APPLICANT SIGNATURE

DATE

PARENT/GUARDIAN SIGNATURE

DATE

PROVIDER NAME: Robert Wood Johnson University Hospital

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