PATIENT APPLICATION

PATIENT APPLICATION

Hospitals and Hospital Based Clinics
Section I: PATIENT/APPLICANT
Today's Date

MonthDayYear
Homeless:
Emergency Application:
Name

First NameMiddle InitialLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

	List Household Members	Relationship to Patient	Date of Birth	Social Security Number
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Section II: Calculation Income

Income Source

	Monthly Income	Annualized Total
1. Gross Employment Income
2. Unearned Income
3. Self-Employment Income
4. Total Income (Lines 1 + 2 + 3)
5. Allowable Deductions (See Worksheet 3)
6. Grand Total Annual Income

	Monthly Income
5. Allowable Deductions (See Worksheet 3)
6. Grand Total Annual Income

Household Size:
PENALTY CLAUSE,CONFIRMATION STATEMENT AND AUTHORIZATION FOR RELEASE OF INFORMATION
CICP ONLY: I certify that the information provided to complete this application is true and correct to the best of my knowledge. I understand that any misrepresentations made with the intent to defraud the CICP program may result in criminal prosecution. Additionally, if I misrepresent my eligibility knowing that I am not eligible, I may be charged with a crime

I authorize the provider to use any information contained in the application to verify my eligibility for assistance under CICP or Hospital Discounted Care, and to obtain records pertaining to eligibility from a bank or other financial institution as defined in section 15-15-201(4), C.R.S., or from any insurance company.

CICP ONLY: I understand that if I am a legal immigrant or legally present non-citizen, that while I am receiving assistance under the CICP, I agree to refrain from executing an affidavit of support for the purpose of sponsoring an immigrant.

CICP ONLY: I understand it is my responsibility to notify the provider of an income or household change that may influence the rating on this application in relation to CICP and failure to do so voids this application for CICP.
YOU HAVE 30 CALENDAR DAYS TO APPEAL YOUR ELIGIBILITY DETERMINATION FOR CICP AND HOSPITAL DISCOUNTED CARE

(Ask your eligibility technician for more information on the appeal process)
Print Patient/Applicant Name
Applicant Signature

Clear
Date

MonthDayYear
Patient was contacted by

phoneemailother
Print Eligibility Technician Name
Eligibility Technician Signature

Clear
Date

MonthDayYear
Application Notes:

	Monthly Income	Annualized Income
Employment Income

Worksheet 2 - Net Self-Employment Income
Does the client operate their business from home?
Square footage of applicant's home:
Square footage used for applicant's home business:
Hours per week applicant works out of their home:
Revenue:

Monthly Annualized

Gross Business Income

	Monthly	Annualized
Gross Business Income

Business Property Expenses:

	Monthly	Annualized
Mortgage/Rent of Business Property
Utilities
____________________
____________________

Other Expenses:

	Monthly	Annualized
Advertising
Business Phone
Business Taxes (non-personal)
Fuel for Business-related Travel
Gross Wages
Insurance
Legal Fees
License/Certification Fees Paid
Merchandise/Cost of goods
Office Supplies
Repairs/Upkeep of Equipment
Tools/Equipment
____________________
____________________

	Monthly	Annualized
Total Expenses
Total Expenses Attributed to Business
Net Profit

Eligibility Technician Signature

Clear
Date

MonthDayYear
Facility
Date

MonthDayYear
This worksheet only needs to be signed and included if the applicant owns their own business.

Worksheet 3 - Allowable Deductions
Household declares they have no deductions
Grand Total
Eligibility Technician Signature

Clear
Date

MonthDayYear
Should be Empty:

	Monthly Income	Annualized Income	Documented	Self-Declared
Social Security Income (SSI)
Social Security Disability Income (SSDI)
Disbursement from Retirement Account
Pension Payments
Payments from Trust Funds
Disbursement from Lottery Winnings

	Monthly Income	Annualized Income	Documented	Self-Declared
Bonuses (enter full amount of bonuses included on pay stubs)
Short Term Disability (enter full amount of payments from STD)
Unemployment Income (enter full amount of current UBI bank)
Tips and Commissions (only if not normal on paystub)
Infrequent Overtime

PATIENT APPLICATION

Section I: PATIENT/APPLICANT

Section II: Calculation Income

PENALTY CLAUSE,CONFIRMATION STATEMENT AND AUTHORIZATION FOR RELEASE OF INFORMATION

Worksheet 1 - Earned and Unearned Income

Worksheet 2 - Net Self-Employment Income

Worksheet 3 - Allowable Deductions