Thank you for your interest in becoming a patient at Medical Outreach Ministries.

Please review the following information carefully.

 

In addition to this completed form, we need copies of several documents to complete your application. You should gather these documents BEFORE you start to complete the online form. You may need to upload or take a picture of these documents as part of your application. You may also bring hard copies of these items to the clinic or submit them via mail or email, if you prefer to fill out a paper application.

 

1. Identification - Must be a current, picture ID - Driver's License, State Issued ID, Voter ID, Salvation Army ID

 

2. Social Security Card - If you do not have your Social Security Card, an official Federal or State tax document with your number on it is acceptable.

 

3. Tax Information

If you do NOT file taxes: Sign Form 4506-T in the online form.

If you file taxes:  Income Tax Return - Form 1040, pages 1-2 of your most recent return. (Prior to April 15, previous year's return is acceptable. After April 15, the most recent year's return is required.)

 

4. Income Information

Must include income information for the entire household.

If you have ZERO income, provide ONE of the following:

• Notarized letter signed by someone who financially assists you. Form will print with your application or contact our office to get a copy.
• Food Stamp Letter

If you have income, provide any that apply to you:

• Benefits letter (ex. SSI, unemployment, food stamps, housing voucher, other government benefits) - Letter must be current and list your name and monthly amount.
• Proof of Child Support/Alimony payments
• Most recent bank statement - Must list your name and beginning and ending balance.

 

PLEASE NOTE: Due to HIPAA rules, you cannot save and return to this form.  Make sure you have gathered all the information that you need to complete it.

 

If you have your documents ready, click "NEXT" to get started!

Application Instructions

 

First, we need to gather some basic information about you and your household.

 

Please complete every field that applies to you.

 

A red * indicates that a field is required.

Next, we need to collect information for the Baptist Health Charity Care/Financial Assistance program. Medical Outreach Ministries partners with Baptist's program to provide our patients with access to labwork, imaging, and specialty services.

 

The next four pages are required for the Baptist Health/Medical Outreach Ministries program.

INCOME and ASSETS

 

Please complete every section that applies to you. Enter "0" if an item does not apply to you.

 

Documentation must be submitted for every source of income and assets listed (ex. benefits letters, income tax returns, etc.).

 

I provide my consent and understand that the information I submit is subject to verification by Baptist Health and subject to review by state and/or federal enforcement agencies, and other entities as required by law. I also understand that Baptist Health reserves the right to ask for additional information.

I certify under the statutes of perjury that the information on these pages is true and correct, and that I do not have the financial means to pay for medical care rendered to the above patient. If my financial situation changes in the upcoming calendar year, I will report these changes to Baptist Health immediately.

*My signature on this application verifies that if I am entitled to any other medical benefits, including, but not limited to, a supplemental insurance policy, I will provide Baptist Health with this information and understand that if I choose not to give any information regarding my supplemental insurance carrier, my application for assistance could be denied, and I will be responsible for the total amount of all outstanding bills at Baptist Health. I read and understand what is not covered by financial assistance and I cannot request a further review/audit of my charges once financial assistance is approved.

*Financial Assistance does not include Medications prescribed for patients to self-administer upon discharge.

I give Baptist Health permission to email me (if email is provided) my approval/denial letter.

My signature below attests that the above information is valid and true.

Financial Assistance does not cover the following services:

• Copays
• Reconstructive surgery which is not medically necessary
• Cosmetic surgery
• Breast implants
• Teeth extractions (excluding radiation, transplant patients or extractions due to trauma)
• Weight loss surgery
• Genetic testing that is required for determining treatment will be covered, but all other genetic testing will be charged to the patient.
• Medications prescribed for patients to self-administer upon discharge.
• Durable medical equipment
• Routine Physical Exams
• Services not normally covered by health insurance

 

These are examples of services not covered under the Financial Assistance Program. This list may not include all exclusions to the program.

 

Should you have questions regarding your particular plan of care, please feel free to call our office at (334) 747-4270.

 

We reserve the right to change or update covered or non-covered services without notice.

 

My signature below verifies that I have read and understand the list and statements stated above.

Medical Outreach Ministries has received Federal funds to assist in operating its Closing the Healthcare Gap program.

Information regarding annual family income is required to determine participant(s) eligibility for public service activities funded by the City of Montgomery through the US Department of Housing & Urban Development's (HUD) Community Development Block Grant (CDBG) Program. Information provided is subject to verification by the agency providing services, the US Department of HUD, and/or the City of Montgomery. 

The next page is a form required by the City of Montgomery for a grant that helps to fund Medical Outreach Ministries.

Please complete and sign.

City of Montgomery, AL

Using the table below, please indicate total annual income of all members of your household. This includes wages, retirement, child support, social security, disability, etc. Select one of the three annual household income options shown.

 

If your household size (including yourself) is not correct, return to page 1 of the application and edit it there.

I understand that State and Federal Law prohibits intentional or willful false statements or misrepresentations concerning financial position or household size. I fully understand that making intentional or willful false statements or misrepresentationss is punishable by fine and/or imprisonment. I further understand that any intentional or willful false statements or misrepresentations or information will be grounds for disqualification to participate in the activity funded by the City of Montgomery through the U.S. Department of Housing and Urban Development (HUD). I certify that all of the information provided is true and exact to the best of my knowledge and belief.

 

CONGRATULATIONS!

 

Your application is finished!

 

The clinic will contact you if we need any further information or clarification.

You may contact the clinic at 334-281-8008 if you have any questions.

 

Click PREVIEW PDF below to view, save, or print your application. Because of HIPAA rules, it will not be available to print or save after you hit Submit.

 

We look forward to serving you!