Get University Hospitals Financial Assistance Application - Uhhospitals

Completing the University Hospitals Financial Assistance Application online is an important step for those seeking financial help. This guide will take you through each section of the form, ensuring you provide all necessary information for your application to be considered.

Follow the steps to successfully complete the financial assistance application.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Enter the patient's name in the designated field, followed by their date of birth and the date of service. This identification is crucial for processing your application.
3. Fill in the patient's address, including the city, state, and zip code. Ensure this information is current and accurate.
4. Indicate the marital status of the patient. Additionally, include the account number associated with the patient's services.
5. Answer whether the patient was an Ohio resident on the date of service by selecting 'Yes' or 'No'.
6. Indicate whether the patient has health insurance covering the services by selecting 'Yes' or 'No'. If 'Yes', provide the name of the insurance company and the policy number, and ensure to attach a copy of the insurance card.
7. Respond to questions about COBRA eligibility and Medicaid benefits by selecting the appropriate answers. If applicable, provide necessary billing information.
8. List all household members, including relationships to the patient and their sources of income. Provide income details for the past three and twelve months, along with income verification documents.
9. If income is reported as $0.00, provide an explanation of financial survival during the specified period.
10. Complete the signature section, ensuring the responsible party signs and dates the application. This acknowledges the truthfulness of the information provided.
11. Upon finishing the form, review all entered information for accuracy. Save your changes, download a copy, print it, or share it as necessary.

Submit your completed financial assistance application online today for timely assistance.