Charity Care Application Form Nj
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FAQ
How do I get an application? o Customer Service Department at 1-800-619-4024. In person at Emergency Departments and Financial Counseling Offices Page 2 You may bring your application to the hospital in person, mail it, fax it, or e-mail it.
Applications are available at all NJ acute care hospitals. Eligibility determination is done at the hospital where the medical service is provided when the completed application is submitted.
You may apply for Financial Assistance within 1 year after discharge from the hospital or receipt of outpatient care. Charity Care is available to New Jersey residents who are uninsured, underinsured, or ineligible for State and Federal programs.
Charity Care Income Criteria and Required Information Valid Identification. Driver's License ? Valid (unexpired) State/County ID. Social Security card. ... Proof of New Jersey Residency for Date(s) of Service. Utility bill for date of service. Valid (unexpired) driver's license with current address. ... Income Information.
Charity Care Proper patient and family identification documents. ... Proof of New Jersey residency as of the date of service (note: under certain circumstances, emergency care is an exception to the residency requirement). ... Proof of gross income. ... Proof of assets as of the date of service.