Get Upmc Financial Assistance Application Information - Upmccom

Filling out the UPMC Financial Assistance Application is a vital step towards accessing financial support for medical care. This guide will provide clear instructions on completing the form online, ensuring you submit all the necessary information for your application.

Follow the steps to complete your financial assistance application effectively.

1. Press the ‘Get Form’ button to obtain the UPMC Financial Assistance Application form and open it in your preferred editor.
2. Begin filling out the application by providing the name of the patient, their date of birth, and their social security number. Ensure that all provided information is accurate.
3. Complete the address section by entering the patient’s current address, daytime phone number, and alternate phone number.
4. List the employer's name for both the patient and their spouse, if applicable. This information helps UPMC assess the household's financial situation.
5. Indicate the requested services by checking the appropriate boxes for UPMC Hospitals and Clinics, UPMC Physician Services, and UPMC Cancer Centers, if applicable.
6. If the patient has received a bill, provide the account or patient ID number as requested.
7. Answer the questions regarding health insurance coverage and previous applications for Medical Assistance. If applicable, include a copy of the Letter of Denial.
8. Complete the household information section by listing all members, their relation to the patient, and their ages, as this will help in determining financial assistance eligibility.
9. Document the monthly household income for each member, including all sources of income, ensuring you attach the necessary proof of income documents as outlined in the checklist.
10. Review the disclaimer section and ensure you understand the confidentiality and verification process before signing the application.
11. Sign the form, include your relationship to the patient, and date it. Remember that a separate application must be completed for each patient requesting financial assistance.
12. Submit your completed application form along with the required documentation by mailing it to the respective UPMC Financial Assistance address.

Start your financial assistance application now by following these steps online.