Charity Care/Financial Assistance Application Form

Charity Care/Financial Assistance Application Form
Screening Information
Do you need an interpreter?*

YesNo
Preferred Language*
Has the patient applied for Medicaid? May be required to apply before being considered for financial assistance*

YesNo
Does the patient receive state public services such as TANF, Basic Food, or WIC?*

YesNo
Is the patient currently homeless?*

YesNo
Is the patient’s medical care need related to a car accident or work injury?*

YesNo
Please Note:
- We cannot guarantee that you will qualify for financial assistance, even if you apply.
- Once you send in your application, we may check all the information and may ask for additional information or proof of income.
- Within 30 calendar days after we receive your completed application and documentation, we will notify you if you qualify for assistance.
Patient and Applicant Information
Patient Name*

First NameMiddle NameLast Name
Gender*

MaleFemaleOther
You may specific a gender
Patient Birth Date*

MonthDayYear
Patient Social Security Number
Optional, but needed for more generous assistance above state law requirements
Person Responsible for Paying Bill

First NameLast Name
Relationship to Patient
Birth Date

MonthDayYear
Social Security Number
Optional, but needed for more generous assistance above state law requirements
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Secondary Phone Number
Email*
Employment status of person responsible for paying bill*

EmployedUnemployedSelf-EmployedStudentDisabledRetiredOther
How long unemployed*
Other*
Family Information
Family Size*
List family members in your household, including you. “Family” includes people related by birth, marriage, or adoption who live together.

Select "Add Family Member" below to add additional family members.
All adult family members’ income must be disclosed. Sources of income include, for example:
- Wages
- Unemployment
- Self-employment
- Worker’s compensation
- Disability
- SSI
- Child/spousal support
- Work study programs (students)
- Pension
- Retirement account distributions
Income Information

REMEMBER: You must include proof of income with your application.
You must provide information on your family’s income. Income verification is required to determine financial assistance.

All family members 18 years old or older must disclose their income. If you cannot provide documentation, you may submit a written signed statement describing your income. Please provide proof for every identified source of income. To be considered complete, a submitted application must include the following income information:
- Complete copy of the most recently filed IRS Form 1040 and all supporting schedules (if applicable)
- Complete copy of the most recently filed Oregon (or other state tax filing) Form 40 and all schedules (if applicable)
- Social Security 1099 Form (if applicable); or
- Current pay stubs (3 months); or
- Approval/denial of eligibility for Medicaid and/or state-funded medical assistance; or
- Approval/denial of eligibility for unemployment compensation.
If you have no proof of income or no income, please attach an additional page with an explanation and last 3 months bank statements.
Upload Proof of Income*

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Expense Information

We use this information to get a more complete picture of your financial situation.
Monthly Household Expenses:
Rent/mortgage
Insurance Premiums
Other Debt/Expenses
(child support, loans, medications, other)
Medical expenses
Utilities
Asset Information

This information may be used if your income is above 101% of the Federal Poverty Guidelines. (Optional)
Current checking account balance
Current savings account balance
Does your family have these other assets? Please check all that apply.

StocksBonds401KHealth Savings Account(s)Trust(s)Property (excluding primary residence)Own a business
Additional Information
Please attach an additional page if there is other information about your current financial situation that you would like us to know, such as a financial hardship, excessive medical expenses, seasonal or temporary income, or personal loss.
Additional Information Upload

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Patient Agreement
I understand that Coquille Valley Hospital may verify information by reviewing credit information and obtaining information from other sources to assist in determining eligibility for financial assistance or payment plans. I affirm that the above information is true and correct to the best of my knowledge. I understand if the financial information I give is determined to be false, the result may be denial of financial assistance, and I may be responsible for and expected to pay for services provided.
Signature*

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Date*

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Charity Care/Financial Assistance Application Form

Screening Information

Patient and Applicant Information

Family Information

Income Information

Expense Information

Asset Information

Additional Information

Patient Agreement