[OLD] Hospital Financial Assistance Application

Hospital Financial Assistance Application
Valid 1 year from date of Approval

Please provide the following information for all members of your family that resides in your household who are related by birth, marriage or adoption. Children over the age of 17 are considered an adult and therefore must fill out a separate application unless claimed on a parents’ income tax. *

	Last & First Name	Date of Birth	Social Security Number	Insurance Info	Med Rec
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6

Please provide the following information for all members of your family that reside in your household who are related by birth, marriage or adoption. Children over the age of 17 are considered an adult and therefore must fill out a separate application unless claimed on a parents’ income tax. *

	Source of Income	Received Weekly, Bi-weekly or Monthly	Amount
Person 1
Person 2
Person 3

Total Gross Income
If you reported zero “0” income, please explain how basic food and housing needs were provided prior to the date of service:
NOTICE OF FLORIDA HOSPITAL FRAUD LAW
Whoever shall, willfully and with intent to defraud, obtains or attempts to obtain goods, products, merchandise or services from any hospital in this state shall be guilty of a misdemeanor of the second degree, punishable as provided in 775.082 or 775.083. If any person shall give to any hospital in this state a false or fictitious name, a false or fictitious address, any other false or fictitious information required to be obtained by such hospital compliance with 382.31 et seq., or shall be assign to any hospital the proceeds of any insurance contract, then knowing that such contract is no longer in force or is invalid or is void for any reason, any such action be prima facie evidence of the intent of such a person to defraud such hospital. Violation of Florida Statute 817.50 is punishable by imprisonment not exceeding sixty (60) days or fine not in excess of $500.00, or both, as may be provided by law upon conviction.
PATIENTS/GUARANTORS’ CERTIFICATION
I HEREBY CERTIFY that I have read the foregoing NOTICE OF FLORIDA HOSPITAL FRAUD LAW and understand the punishment for violation of the same. Further, I certify that the above and all addenda provided to Ed Fraser Memorial Hospital on this date is true, exact and complete, to the best of my knowledge and that I have not provided any information that is false or fictitious whatsoever. I understand that Ed Fraser Memorial Hospital may verify any or all of this information and that discrepancies discovered in the verification process may constitute fraud within the meaning of the foregoing statue and that I may then be criminally prosecuted for said fraud, by the State of Florida through the Office of the State Attorney. I also understand that I can be sued in Civil Court for fraud and other causes of action. I also understand, if approved, this program only covers technical charges billed by Ed Fraser Memorial Hospital, Baker County Medical Services Emergency room physician charges & professional radiology charges and any other BCHC employed specialty physician excluding Elective or Cosmetic Services. Any other charges incurred from physicians owned and operated by Baker County Medical Services or Baker Rural Health Center are NOT eligible under this policy. My signature also certifies that the above income information is accurate and true to the best of my knowledge.
Signature of Guarantor *

Clear
Date *

Month Day Year
Date
PL ACCOUNT #
Application Status

Approved Denied Pending
Approval by
Date

Month Day Year
Date
Expires

Month Day Year
Date
File Upload

Cancel of
Should be Empty:

Hospital Financial Assistance Application

NOTICE OF FLORIDA HOSPITAL FRAUD LAW

PATIENTS/GUARANTORS’ CERTIFICATION