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Get Atlanticare Charity Care
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How to fill out the Atlanticare Charity Care online
Filling out the Atlanticare Charity Care application online can be a straightforward process when you have the right guidance. This guide will help you navigate through the various sections and fields of the form to ensure you provide all the necessary information accurately.
Follow the steps to complete the application successfully.
- Press the ‘Get Form’ button to receive the application form and access it for completion.
- Begin by filling out Section I: Personal Information. Provide your full name, social security number, and the application's date. Include the initial and requested dates of service, your street address, telephone number, city, state, and ZIP code, family size, citizenship status, and proof of residency in New Jersey. If applicable, include the name of the guarantor.
- Move to Section II: Assets Criteria. Here, you will list individual and family assets. Specify the types of assets you have, including cash, savings accounts, checking accounts, certificates of deposit, real estate equity, and other assets. Make sure to total the assets at the end of this section.
- Proceed to Section III: Income Criteria. List all sources of income, such as salary, public assistance, social security benefits, unemployment compensation, veteran's benefits, alimony, and other monetary support. Calculate and provide your total gross income based on the specified time frames of either last three months, last twelve months, or last one month.
- In Section IV: Certification By Applicant, read the statements carefully. You will need to sign and date this section to certify that the information you provided is accurate and complete. Indicate your understanding of the responsibilities related to any changes in income or assets.
- If applicable, complete additional attestation statements regarding income, assets, medical coverage, and residency. Ensure you sign where indicated and provide any necessary details relevant to your situation.
- Finally, review the entire application to confirm that all fields are filled correctly. Once satisfied, you can save your changes, download the completed application, or share it as necessary.
Take the first step towards receiving assistance by completing your Atlanticare Charity Care application online today.
The New Jersey Hospital Care Payment Assistance Program (Charity Care) is available to patients for inpatient and outpatient services at all acute care hospitals throughout New Jersey. Medically necessary services may be eligible for patients who meet income and asset criteria.