Healthcare Indigent Application

HEALTHCARE INDIGENT APPLICATION

This application requests information to determine eligibility for reduced-cost or free healthcare services due to financial hardship. Complete all sections to the best of your ability. Submission of false information may subject the applicant to denial of benefits and applicable penalties under law.

1. Applicant Information

Date of Birth:    Gender: Male Female Other

2. Household Composition

Number of persons in household:

List household members (include applicant). Attach additional pages if necessary.

3. Income and Resources

Employment status: Employed Unemployed Retired Student

Other income sources (check all that apply):

SSI    SSDI    Unemployment    TANF    Child Support    Pension    None

4. Insurance and Coverage

Do you have health insurance? Yes No

5. Medical Need and Services Requested

Is this an urgent or emergent treatment request? Yes No

6. Monthly Expenses

7. Documentation Checklist

Please indicate which supporting documents are provided with this application:

Government-issued photo ID

Pay stubs / award letters / benefit statements

Medical bills or cost estimates

Insurance denial or explanation of benefits

Bank statements (last 3 months)

8. Authorization, Certification, and Acknowledgments

I certify under penalty of law that the information provided in this application, including all attachments, is true, correct, and complete to the best of my knowledge. I understand that intentional misrepresentation or omission of material facts may result in denial, discontinuation of benefits, and potential civil or criminal penalties.

I authorize the release of medical, financial, and eligibility information necessary to verify the facts in this application to the healthcare facility and any agents acting on its behalf for purposes of determining eligibility for indigent care or reduced-fee services. This authorization includes, but is not limited to, release of medical records, billing statements, pay records, and benefit statements.

I understand that this authorization will remain in effect only for the period necessary to determine eligibility and to administer any awarded benefits. This authorization expires on:

I acknowledge that I have been provided with the facility's privacy practices and that the facility may use and disclose my protected health information consistent with applicable law to determine eligibility for financial assistance. I understand I may revoke this authorization in writing at any time, except to the extent the facility has already acted in reliance on this authorization.

I understand that a determination of eligibility is administrative and does not guarantee that all charges will be covered. If financial assistance is approved, I agree to cooperate with any recovery or cost-sharing arrangements specified in the approval notice.

9. Appeal and Grievance Rights

If this application is denied or if you disagree with the determination, you have the right to request a written explanation of the decision and to appeal the determination according to the facility's internal appeal procedures. Appeals must be submitted in writing within the time frame specified in the denial notice.

Applicant signature below constitutes acknowledgment of the statements above, consent to verification of information, and agreement to the terms as stated.

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