Discount Payment Financial Assistance Application Form
Provided in Accordance with Cal. Health & Safety Code § 127425(e)(5)
Application Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Service
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Name
First Name
Last Name
Account Number
Hospital
Anaheim Global Medical Center
Hemet Global Medical Center
Chapman Global Medical Center
Menifee Global Medical Center
Orange County Global Medical Center
Victor Valley Global Medical Center
South Coast Global Medical Center
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1) Was the patient a resident of California at the time of service?
Yes
No
2) Did the patient have medical insurance at the time of service?
Yes
No
3) Was the patient an active Medicaid recipient at the time of service?
Yes
No
If you answered yes to questions 2) or 3), please upload a copy of your insurance or Medicaid card to this application.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Income
Income is determined by patient's income 12 months prior to when the patient was first billed. For persons 18 yearsof age and older, a patient's family means a spouse, domestic partner (as defined in Section 297 of the Family Code), or dependent children under 21 years of age (or any age if disabled), whether living at home or not. For persons under 18 years of age, or for a dependent child 18 to 20 years of age, a patient's family means parents, caretaker relatives, and other dependent children under 21 years of age (or any age if disabled) of a parent or caretaker relative. Domestic Partner: (Family Code Section 297) (a) Domestic partners are two adults who have chosen to share one another's lives in an intimate and committed relationship of mutual caring; (b) A domestic partnership is established in California when both persons file a Declaration of Domestic Partnership with the Secretary of State, and, at the time of filing, all of the following requirements are met: (i) Neither personis married to someone else or is a member of another domestic partnership with someone else that has not been terminated, dissolved, or adjudged a nullity. (ii) The two persons are not related by blood in a way that would prevent them from being married to each other in this state. (iii) Both persons are at least 18 years of age, or, in the case of a minor, a court order is obtained in accordance with Section 297.1 of the Family Code. (iv) Both persons are capable of consenting to the domestic partnership.
Rows
Family Member's Name
Age
Date of Birth
Relationship to Patient
1
2
3
4
5
6
7
8
9
Please upload additional family member information if applicable.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Proof of income must be uploaded at the time of application (e.g., three months of pay stubs or most recent tax return (IRS form 1040), etc.).
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If you report $0 income, please upload a written statement of how you (or the patient) are surviving financially, include who provides food, shelter, transportation, etc. and how long you have been without income.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Monthly Expenses
Rows
Monthly Expense
Monthly Rent / Mortgage
Utilities
Car Payment
Medical Expenses
Insurance Premiums (life, home, car, medical)
Clothing, groceries, household goods
Other debt/expenses (e.g., child support, loans, other)
My signature below certifies that everything I have stated on this application is correct and subject to review under audit. I understand, but if the information I provide is determined to be false, financial assistance may be denied, and I may be responsible for paying for the services provided.
For any questions regarding this form, please contact Central Business Office's Patient Financial Services at 800-270-0702.
Continue
Should be Empty: