Financial Assistance Application

Financial Assistance Application

This application is only valid for services provided by Southwest General Hospital
If you believe you may qualify for financial assistance, complete this application. The entire application, including signature must be completed and signed to be considered
Patient Name*
Patient Name
Date of Birth*

MonthDayYear
Data of Birth
Marital Status*
Marital Status
Address*
Address
City*
City
County*
County
Zip*
Zip Code
Phone
Phone
If you are applying for assistance for multiple accounts, you must complete a separate application for each month of service.
Date of Service
Date(s) of Service
Account #
Account #(s)
Were you an Ohio resident on this date of service?
Resident of Ohio is required to use this form.
Ohio Resident?*

YesNo
Do you have health insurance covering these services?
If yes, enter information below.
Health Insurance?*

YesNo
Insurance Company
Name of Insurance Company
Policy #
Policy #
Group #
Group #
Are you eligible for COBRA?
Cobra?*

YesNo
Do you have Medicaid benefits?
Medicaid?*

YesNo
Medicaid #
If Yes, Enter Number
Please list all household members below. Include parents, spouse (regardless if they live in the home) & children (natural or adoptive) under the age of 18 living in the home along with the patient. You may be asked for copies of income verifications such as pay stubs, social security determinations, workers compensation, and tax returns. Call Financial Counseling at (440) 816-8249 weekdays 8 a.m. - 4:30 p.m. to discuss other evidence that may be provided to demonstrate eligibility.
Household Members*
If you reported $0.00 income above, please provide a brief explanation of how you (or the patient) survived financially during the period requested above:
If Zero Income
By my signature below, I attest to the best of my knowledge and belief that the answers on this application are true. I understand that it is unlawful to knowingly submit false information to obtain government benefits. I further understand that other parties may rely on this information I provide herein. I hereby authorize them to do so.
Today's Date

MonthDayYear
Today's Date
Responsible Party Signature

Clear
Should be Empty: