You’ve confirmed you are eligible for charity care, and have gotten a copy of the application. Now it’s time to fill it out.
Ways to fill out your application form
1. Print it out and fill it out by hand
This is by far the easiest option and is totally ok. Just make sure your handwriting is easy to read and use black or blue ink.
2. Use a PDF editing tool on your computer
If you don’t have a tool on your computer, there are free online tools, such as Sejda.com. Upload the document into the tool, then click where you want to type.
Information to share on your application form
Start by reading the instructions and the application carefully.
The hospital is probably going to ask questions about:
- What is the patient’s name and date of birth?
- Who is responsible for paying the bill and their contact information? This is sometimes called the guarantor. A child’s bill, for example, would be paid by their parent.
- Who are the members of the household?
- How much money does each person in the household make? Where do they work?
- What are the monthly expenses of the household?
- How much money does the family have in bank accounts or other investments?
- Does anyone in the family receive any public assistance?
Fill in every question on the application that you can. If the answer is $0 or you don’t know, it’s ok to write “I don’t know,” but try to give them as much information as possible. Doing so will help make your case that you qualify for charity care.
Be sure to sign the application where asked for your signature. Some hospitals also require a spouse or witness to sign. Try to give every signature asked for when you first apply. You don’t want to have to fix things later, and you don’t want to give the hospital a reason to deny your application.
Attach the required documents to your application
In addition to the application, the hospital is definitely going to ask you for proof that what you say in your application is true. Almost every hospital will ask for copies of:
- Your most recent three months of paystubs
- Last year’s tax returns
Some hospitals will also ask for a lot of other documents. These might include:
- Proof that you live in the state or county the hospital serves, like a utility bill with your name and address on it
- Proof of health insurance, if you have it
- Copies of bank account statements
- Copies of unemployment benefit letters
- Proof you have applied for Medicaid or other public health insurance programs
Carefully gather all of the requested documents. Hospitals may deny your application if you don’t submit everything they require.