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Get Vanderbilt Medical Center Financial Assistance Form

Vanderbilt University Medical Center Financial Assistance Application PATIENT INFORMATION Today s Date Patient Full Name Last First Middle Date of Birth Is patient a minor Yes or No Phone Number - Area Code Number Account s Address Street Address Apartment/Unit City State Zip Code RESPONSIBLE PARTY INFORMATION Check here if same as patient Guarantor Name Relationship to Patient Date of Birth HOUSEHOLD INFORMATION 1. Number of People in Household 2. Total Yearly Household Income We need your permission to check your credit report information during the processing of your application to determine if you are qualified for financial assistance. Our search will not affect your credit score. Other lenders will not see this request. If you review your credit report you will see the inquiry by Vanderbilt and Search America* Please sign below if you give your permission to review your credit report for application for financial assistance. Guarantor Signature Today s Date In 4 to 6 weeks you will receive a letter to inform you if you are eligible for financial assistance for an approved service. If you receive an approval letter it does not mean that all services at Vanderbilt are approved or that future services will be approved for financial assistance. You will need to reapply each time you receive a new bill* For faster service please call our Vanderbilt Patient Billing Customer Service Team at 888-274-7849 to reapply. You can also mail in a new application* If you receive a letter informing you are not eligible for financial assistance and wish to appeal the decision you can appeal the decision by mailing or faxing a completed Vanderbilt Financial Assistance Appeal Application attaching proof of income. Mail or Fax Application Questions Fax 615-936-0620 Vanderbilt Patient Billing One Hundred Oaks 719 Thompson Lane Suite 30330 Nashville TN 37204 Call 888-274-7849 Monday-Friday 8am-5pm. Number of People in Household 2. Total Yearly Household Income We need your permission to check your credit report information during the processing of your application to determine if you are qualified for financial assistance. Our search will not affect your credit score. Other lenders will not see this request. If you review your credit report you will see the inquiry by Vanderbilt and Search America* Please sign below if you give your permission to review your credit report for application for financial assistance. Our search will not affect your credit score. Other lenders will not see this request. If you review your credit report you will see the inquiry by Vanderbilt and Search America* Please sign below if you give your permission to review your credit report for application for financial assistance. Guarantor Signature Today s Date In 4 to 6 weeks you will receive a letter to inform you if you are eligible for financial assistance for an approved service. Guarantor Signature Today s Date In 4 to 6 weeks you will receive a letter to inform you if you are eligible for financial assistance for an approved service. If you receive an approval letter it does not mean that all services at Vanderbilt are approved or that future services will be approved for financial assistance..

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