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  • Obleness Hcap Form

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HOSPITAL CARE ASSURANCE PROGRAM APPLICATION O'BLENESS CARE ASSURANCE PROGRAM *Please complete this form using blue or black ink* ACCOUNT NUMBER(S): , , , PATIENT NAME DATE OF BIRTH / / DATE OF APPLICATION.

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Only HOSPITALs accept HCAP applications. To be eligible for HCAP: You should be an Ohio resident. You are not a recipient of the Medicaid program. Your family income is at or below the current Federal Poverty Guidelines OR you are covered by the Disability Assistance Program.

We are pleased to offer The OhioHealth Financial Assistance Program (FAP), which provides free or discounted services to eligible patients for emergency or medically necessary services. Patients seeking financial assistance must apply for the program.

For more information about charity care and medical financial assistance, please contact customer service at (614) 566.1505.

The Hospital Care Assurance Program, or HCAP, offers help with unpaid hospital bills to Ohioans at or below the federal poverty level and who are ineligible for Medicaid coverage.

To be eligible for HCAP: You should be an Ohio resident. You are not a recipient of the Medicaid program. Your family income is at or below the current Federal Poverty Guidelines OR you are covered by the Disability Assistance Program.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232