Get Indigent Care Application

Completing the Indigent Care Application online is a straightforward process designed to assist users in applying for the Indigent Care Trust Fund. This guide will provide step-by-step instructions to help you navigate through the application effectively.

Follow the steps to successfully complete the Indigent Care Application.

1. Click the ‘Get Form’ button to access the Indigent Care Application. This will open the form for you to begin filling it out.
2. Identify and select the unique identifier for your hospital from the pull-down list in the Facility UID field. Ensure that the correct UID is used for accurate data representation.
3. Enter a descriptive name for your primary care project in the Project Name field. This will help in tracking your application in future reviews.
4. In the Summary Purpose section, select the planned service from the pull-down menu. Make sure to choose a pre-approved service marked with an asterisk if applicable.
5. Describe the targeted population you intend to serve in the Targeted Population field. Be specific about the group that will benefit from your project.
6. Provide a brief assessment of the community's health needs in the Assessed Health Need field. This should outline how your project aligns with local health concerns.
7. In the Project Description field, list the services provided and any necessary materials funded by the ICTF. Clarity is crucial here for reviewers to understand your proposal.
8. Outline the desired Projected Outcomes of your initiative, ensuring they correlate with the assessed health needs you've identified.
9. Specify the full legal name of the provider of services in the Provider of Service field. If applicable, also provide the name of the contractor or local provider.
10. Select the county where the service will be located using the pull-down menu in the Provider (Service Location) County field.
11. Enter the relevant zip code for your service location in the Provider (Service Location) Zip field.
12. Fill in the Begin Date and End Date for the project in their respective fields.
13. If this project is a continuation of a prior year’s project, indicate this by checking the box in the Continuation from Prior Year section.
14. Fill in the total Project Budget required for this initiative in the Project Budget field.
15. Specify the amount of ICTF Primary Care Funds included in your budget in the ICTF Primary Care Funds in the Budget field.
16. Enter the counties eligible for receiving services in the Service Area field, ensuring all earlier fields are completed first.
17. After filling out all projects, switch to the Signature Form using the pull-down menu. Complete the required information, including the authorized signature.
18. Finally, once all input is complete, save your changes, create a zip file for emailing, and ensure you have a backup of your completed forms for your records.

Begin completing your Indigent Care Application online today and take the first step towards receiving the support you need.