Financial Assistance Application Form
Provided in Accordance with Cal. Health & Safety Code § 127425(e)(5)
Application Date
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Month
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Day
Year
Date
Date of Service
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Month
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Day
Year
Date
Patient Name
First Name
Last Name
Account Number
Hospital
Anaheim Global Medical Center
Hemet Global Medical Center
Chapman Global Medical Center
Menifee Global Medical Center
Orange County Global Medical Center
Victor Valley Global Medical Center
South Coast Global Medical Center
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth
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Month
-
Day
Year
Date
1) Was the patient a resident of California at the time of service?
Yes
No
2) Did the patient have medical insurance at the time of service?
Yes
No
3) Was the patient an active Medicaid recipient at the time of service?
Yes
No
If you answered yes to questions 2) or 3), please upload a copy of your insurance or Medicaid card to this application.
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Income
• All adult family members' income must be disclosed. Income includes gross (before taxes) wages, rental income, unemployment compensation, Social Security benefits, public assistance, dividends and interest, etc. • "Family" is defined as follows: (i) for persons 18 years of age and older, family means spouse, domestic partner, and dependent children under 21 years of age, whether living at home or not; and (ii) for persons under 18 years of age, family means parents, caretaker relatives, and other children under 21 years of age of parent or caretaker relative. If the patient is a minor, the "family" is defined as the patient, the patient's natural or adoptive parents, and the parent's other children (natural or adoptive) who live in the patient's home.
Family Member's Name
Age
Date of Birth
Relationship to Patient
Source of Income or Employer Name
Income For 3 Months prior to date of service
Income For 12 Months prior to date of service
1
2
3
4
Please upload additional family member information if applicable.
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Proof of income must be uploaded at the time of application (e.g., three months of pay stubs, most recent tax return (IRS form 1040), etc.).
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If you report $0 income, please upload a written statement of how you (or the patient) are surviving financially, include who provides food, shelter, transportation, etc. and how long you have been without income.
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Monthly Expenses
Monthly Expense
Monthly Rent / Mortgage
Utilities
Car Payment
Medical Expenses
Insurance Premiums (life, home, car, medical)
Clothing, groceries, household goods
Other debt/expenses (e.g., child support, loans, other)
Assets (This information may be used if your income is above 200% of Federal Poverty Level guidelines to determine whether you may be eligible for discounted care.)
Assets
Checking account
Savings account
Business ownership
Stocks and bonds
Real estate (excluding primary residence)
My signature below certifies that everything I have stated on this application is correct and subject to review under audit. I understand, but if the information I provide is determined to be false, financial assistance may be denied, and I may be responsible for paying for the services provided.
For any questions regarding this form, please contact Central Business Office's Patient Financial Services at 800-270-0702.
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