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  • Cleveland Clinic Hcap Application Fill In Form

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Curity Pension, Dividends, Interest, Rental Income Unemployment, Workers Compensation, FINANCIAL ASSISTANCE PROGRAM Current Monthly Gross Income Amount Patient $ $ Current Monthly Gross Income Amount Spouse/Other Total Family Income for 3 months prior to date of service $ Type of Income verification attached proof of income is required to process your application Most Recent Income Tax Return, Copy of most recent W-2 s, copy of pay stubs (for 3 previous months.) $ $ $ Social S.

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Related content

2015 Form 990 Schedule H The Cleveland Clinic...
May 11, 2015 — Complete if the organization answered "Yes" on Form 990, Part IV...
Learn more
Ohio Department of Medicaid
Visit coronavirus.ohio.gov or call 1-833-4-ASK-ODH for answers. ... (03/24/2021); Ohio...
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Related links form

OH Income Tax Return - Maumee 2022 OH Income Tax Return - City Of Brunswick 2022 MA DoR Schedule B 2022 CA FTB 100 2022

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Only HOSPITALs accept HCAP applications. To be eligible for HCAP: You should be an Ohio resident. You are not a recipient of the Medicaid program. Your family income is at or below the current Federal Poverty Guidelines OR you are covered by the Disability Assistance Program.

HCAP is Ohio's version of the federally required Disproportionate Share Hospital program. HCAP provides funding for hospitals that provide a disproportionate share of basic medically necessary hospital level services to qualified patients.

Charity care and medical financial assistance is offered to patients with limited or no resources and inadequate medical insurance coverage. Eligibility is determined by family income.

Patients can be referred for admission directly by their physician, social worker or family member. Patients and family members may call our admissions department directly at 216.455. 6444.

Cleveland Clinic Health System's policy is to provide Emergency Care and Medically Necessary Care on a non-profit basis to patients without regard to race, creed, or ability to pay.

Questions about your medical bill If you have questions about your bill, contact the OhioHealth Customer Call Center at (614) 566.5594 or (800) 837.2455.

The Hospital Care Assurance Program, or HCAP, offers help with unpaid hospital bills to Ohioans at or below the federal poverty level and who are ineligible for Medicaid coverage.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232