Get Summa Financial Assistance

Filling out the Summa Financial Assistance application is an important step for users seeking financial support for hospital services. This guide will provide a comprehensive, step-by-step approach to completing the application accurately and efficiently.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the application form and open it in your preferred editor.
2. Begin by entering the patient’s name, including last name and first name, as well as their social security number and street address. Ensure all information is printed clearly.
3. Indicate the marital status of the patient by selecting one of the options: single, married, widowed, or separated. Next, provide the date of service and date of birth for the patient.
4. Fill in the patient's employment status at the time of service by selecting one of the following: employed, retired, or unemployed. Also, add the hospital account number and ZIP code.
5. Answer the questions regarding residency and Medicaid status. Specify if the patient was a resident of Ohio and if they were an active Medicaid recipient at the time of service. If applicable, provide the Medicaid billing number.
6. Indicate if the patient received disability assistance before the hospital stay. Also, provide the name and social security number of the spouse, if relevant, and their employment status.
7. List family members, including the patient's children under 18 years old and relevant information about their relationship to the patient. Provide their dates of birth and gross income as earned within the three months prior to the month of service.
8. In the income section, summarize all sources of income from the patient and spouse, completing the required fields accurately. If there is no income, use the provided statement to explain how basic needs were met.
9. Review the application for accuracy, ensure that all fields are completed, and sign the document as the patient or legal representative. A hospital representative will also need to sign.
10. Once everything is completed and signed, save your changes, and you may choose to download, print, or share the form.

Complete your financial assistance application online today to ensure your access to necessary healthcare services.