Financial Assistance Application

Financial Assistance Application
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
State
State
Zip
Zip Code
Phone
Phone
date of Service
Date(s) of Service
Account #
Account #(s)
Were you an Ohio resident on this date of service?
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, spouses (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 Customer Service 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: