Get Financial Assistance

This guide provides step-by-step instructions to assist users in filling out the Financial Assistance form online. Our goal is to help you navigate the application process with clarity and confidence.

Follow the steps to successfully complete the Financial Assistance application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide your name, family’s street address, city, state, zip code, and phone number. Ensure the information is accurate as it will be crucial for communication.
3. Enter the date(s) of service for which you are applying for assistance. Remember that separate applications are needed for services spanning more than three months.
4. Input your account number(s) associated with the date(s) of service. Applications will only be considered if submitted within 240 days from the first statement date.
5. Answer the eligibility questions regarding U.S. citizenship, residency status in Ohio, and current Medicaid or Disability Assistance status. Provide explanations where applicable.
6. Indicate whether the patient had health insurance at the time of service. If yes, include the insurance name.
7. Detail the total gross income for all household members. Complete the Income Verification Checklist for accuracy.
8. If applicable, explain any circumstances regarding $0 or minimal income on the designated area of the form or attached checklist.
9. Sign and date the application to certify that the information provided is true and complete. Know that providing false information can lead to legal consequences.
10. Return the completed application to the Financial Counselor at Health System. You may also call the Customer Service Line for assistance if needed.

Start your application for financial assistance by filling out the form online today.