Get Financial Assistance Summary - Montefiore Medical Center - Montefiore

Navigating financial assistance options can be challenging, but filling out the Financial Assistance Summary at Montefiore Medical Center is a step toward receiving the help you need. This guide provides clear, step-by-step instructions to ensure a smooth online application process.

Follow the steps to fill out the Financial Assistance Summary online.

1. Press the ‘Get Form’ button to obtain the Financial Assistance Summary and open it for editing.
2. Begin by providing the applicant information, including the patient’s name, social security number, address, and contact details. Ensure all fields are filled out accurately to avoid processing delays.
3. Indicate the relationship to the patient by selecting from the available options such as spouse, child, parent, or other. This step is important for accurately assessing eligibility.
4. Fill in the gross annual income and family size. This information will help determine eligibility for discounts based on income limits. Refer to the financial aid eligibility chart for guidance on income thresholds.
5. Gather and include acceptable proof of income documentation, such as pay stubs, Social Security statements, or tax returns, as required.
6. Review the application statement section where you will affirm your authorizations for assignment of benefits and the release of information related to medical services. Ensure that you understand and agree to the terms provided.
7. Sign and date the application. If you are completing this on behalf of the applicant, indicate your relationship to the patient and provide your signature.
8. After ensuring that all sections of the form are completed accurately, save the changes, download a copy for your records, and either print the form or prepare it for online submission.
9. Submit the completed Financial Assistance Summary form and all required documentation to Montefiore Medical Center’s Patient Financial Services Department at 111 East 210th Street, Bronx, NY 10467, or bring it to Room RS-001.
10. Once submitted, you may disregard any bills while your application is under review. Expect to receive notification of your application status within 30 days.

Complete your Financial Assistance Summary online today to begin the process of receiving the support you need.