Get Application - University Of Toledo Medical Center - Utmc Utoledo

Completing the Application for the University of Toledo Medical Center is an important step in securing the necessary hospital care assurance. This guide provides clear, step-by-step instructions to help you navigate the application form effectively and confidently.

Follow the steps to successfully complete your application online.

1. Use the ‘Get Form’ button to access the application. This will open the document for you to fill out in the editor.
2. Fill out the patient name and phone number in the designated fields. Ensure that the contact details are accurate to avoid any delays.
3. Enter the dates of service alongside the address of the patient. It is essential to provide complete and correct information here.
4. Identify the family member interviewed and provide any additional dates of service if applicable. This information helps in maintaining accurate records.
5. Provide the city, state, and zip code associated with the patient’s address. Double-check these details to ensure they are correct.
6. Indicate the responsible party's name and account numbers, if available. Ensure you have all accounts related to the patient’s services.
7. Answer the question regarding Ohio residency at the time of hospital service by selecting ‘Yes’ or ‘No’.
8. Indicate whether the patient had health or auto insurance for the dates of service. If yes, fill in the insurance company name, policy number, and group number.
9. If applicable, confirm whether the patient has Medicaid benefits. If so, provide the billing number and attach a copy of the Medicaid card.
10. Similarly, if applicable, state whether the patient has Disability Assistance and provide the required billing number along with a copy of the DA card.
11. List all family members living in the home, including the patient, by filling in their relationships, ages, and sources of income.
12. Document the income for the three months and twelve months preceding the date of service. This is crucial for verifying financial eligibility.
13. If the income is reported as $0.00, provide a brief explanation detailing how the patient or responsible party managed financially during that period.
14. Complete the application by having the responsible party sign and date the form. Note that without the signature, the application is void.
15. Once all sections are filled, you can save changes, download, print, or share the completed form per your needs.

Start filling out your University of Toledo Medical Center application online today!