Get Application For Financial Assistance - Mercy Health

Filling out the Application For Financial Assistance at Mercy Health can help users receive the financial aid they need for healthcare services. This guide provides a clear, step-by-step approach to ensure that your application is completed accurately and efficiently online.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to access the application form online.
2. Identify the Mercy Health hospital you are applying for financial aid. Select from the available options: Anderson, Clermont, Fairfield, The Jewish Hospital, Mt. Airy, or Western Hills.
3. Provide your account number. This number is crucial and should correspond to only one account.
4. Input the patient’s full name as it appears on the health records.
5. Complete the patient’s address, ensuring that you fill in the city, state, and ZIP code accurately. Also, provide a contact phone number.
6. Indicate whether the patient was a resident of Ohio on the date of service by selecting ‘Yes’ or ‘No.’
7. Select whether the patient had health coverage on the date of service. If ‘Yes,’ prepare to attach a copy of the insurance card(s) with the application.
8. List all household members, along with their total before-tax income earned prior to the date of service. Use the provided definitions for ‘household’ and ‘income’ to guide your entries.
9. Complete the Support Statement if no income was received in the three months prior to the date of service, explaining how the household was supported during that time.
10. Ensure that the patient’s signature is provided. If the applicant is not the patient, they should sign and indicate their relationship to the patient.
11. Thoroughly review all entries for accuracy before submitting. You can then save changes, download, or print the form for your records.

Complete your application for financial assistance online today to ensure you receive the support you need.