APPLICATION FOR DETERMINATION OF ELIGIBILITY FOR FINANCIAL ASSISTANCE

Important: YOU MAY BE ABLE TO RECEIVE FREE OR DISCOUNTED CARE: Completing this application will help the Hospital & Health Services/Family Medicine determine if you can receive free or discounted services or other public programs that can help pay for healthcare. Please complete this form and submit it to the hospital Patient Financial Services department or by mail at 123 Apple Avenue, Gering NE, 69341 to apply for free or discounted care within 90 days following the date of discharge or receipt of outpatient care.

Patient Information

IF YOU ARE UNINSURED, A SOCIAL SECURITY NUMBER IS NOT REQUIRED TO QUALIFY FOR FREE OR DISCOUNTED CARE. However, a Social Security Number is required for some public programs, including Medicaid. Providing a Social Security Number is not required but will help the hospital determine whether you qualify for any public programs.

Employer Information

Household Information

Full Name Age Relationship Edit

Asset Information

Asset information must be provided for applicants but will not be used to determine discount eligibility for Family Medicine (RHC) services. Asset information will be utilized in determination of discount eligibility for Hospital services or the maximum collectible amount applicable for an uninsured patient.

Income Information

If patient meets the presumptive eligibility criteria or is otherwise presumptively eligible by virtue of the patient’s family income, the patient is not required to complete the monthly obligation section

Expenses Information

Optional Information

We are required to ask the following demographic information. Your response or lack thereof has no influence on financial assistance determination.

Documentation Upload

Please submit the following: Family Income Documentation (submit one or more of the following) - copies of the 2 most recent pay stubs; if pay stubs not available instead submit copies of the most recent tax return, copies or the most recent W-2 form and 1099 form, written verification from an employer if paid in cash, and/or copies of monthly benefits statement from Social Security.

Please also provide copies of the following items: Hospital Determination of Eligibility for Financial Assistance (Application Form #123), forms approving or denying assistance from the Department of Public Aid (you must apply for medical assistance if you meet one of the following criteria: children living in the home, you are permanently disabled, pregnant or age 65 or above.), checking account statements (past 3 months), savings account statements (past 3 months).

Acknowledgement & Electronic Signature

Patient acknowledges that he or she has made a good faith effort to provide all information requested in the application to assist the hospital in determining whether the patient is eligible for financial assistance. I certify that the information in this application is true and correct to the best of my knowledge. I will apply for any state, federal, local assistance for which I may be eligible to help pay for this hospital bill. I understand that the information provided may be verified by the hospital, and I authorize the hospital to contact third parties to verify the accuracy of the information in this application. I understand that if I knowingly provide untrue information in this application, I will be ineligible for financial assistance, any financial assistance granted to me may be reversed, and I will be responsible for the payment of the hospital bill.