Get Reduced Cost Of Care Application - Lvhn

Filling out the Reduced Cost of Care Application from Lehigh Valley Health Network (LVHN) can help you receive financial assistance for medically necessary care. This guide provides clear and supportive instructions designed to assist you in completing the application process online.

Follow the steps to successfully complete your application.

1. Click 'Get Form' button to access the application and open it in your preferred document editor.
2. Begin by entering patient information in the designated fields. This includes the name of the patient, their date of birth, medical record number, and social security number.
3. Provide the patient's address, including number and street, city, state, zip code, and county. Ensure all information is accurate.
4. Input the patient's daytime and alternate phone numbers along with their employer's name. If applicable, also include information regarding the spouse and their employer.
5. List the dependents as reported on the federal tax return, ensuring you meet the eligibility criteria listed in the application.
6. In the 'Medical Resources' section, enter details regarding any health savings accounts or flexible spending accounts.
7. Enter all insurance information required, including the name of the insurance company, subscriber name, ID number, group number, claims address, and phone number.
8. Indicate whether you have applied for medical assistance in the past six months and provide necessary documentation if applicable.
9. Continue to provide details about any accidents if relevant, including circumstances and attorney contact information.
10. Document household income for yourself and other members. Ensure all income sources are listed and provide supporting documentation as required.
11. Review and certify that all information provided is true and sign the application, including date and your relationship to the patient.
12. Once the application is completed, save changes, and prepare for submission by printing or sharing the completed form as necessary.

Complete your application online today to take advantage of LVHN's Financial Assistance Program!