APPLICATION FOR FINANCIAL ASSISTANCE
STEP 1: COMPLETE INFORMATION BELOW: (ALL QUESTIONS MUST BE ANSWERED)
PATIENT NAME:
SOCIAL SECURITY#(REQUIRED):
ADDRESS: BIRTH DATE:
CITY, STATE, ZIP: MEDICAL RECORD NO:
HOME TELEPHONE NUMBER: WORK TELEPHONE NUMBER:
MARITAL STATUS: (CIRCLE ONE) SINGLE MARRIED DIVORCED SEPARATED WIDOWED
STEP 2: FILL OUT INCOME/ASSET INFORMATION: IF ADDITIONAL SPACE IS REQUIRED PLEASE ATTACH SEPARATE PIECE OF PAPER.
FAMILY MEMBERS –
INCLUDE SELF,
SPOUSE CHILDREN
UNDER 18
SEX
SOCIAL SECURITY # (REQUIRED)
BIRTH
DATE
RELATION
TO
PATIENT
MONTHLY GROSS
WAGES/
SOCIAL
SECURITY, ETC.
EMPLOYER
NAME
EMPLOYER
PHONE NO.
DO YOU HAVE INSURANCE WHICH COVERS ALL OR PART OF THE COST OF PRESCRIPTION MEDICATIONS? YES / NO. IF YES LIST THE INSURANCE(S) NAMES
BELOW WITH MEMBER IDS AND GROUP #S:
_____________________________________________________________________________________________________________________________
IF UNEMPLOYED, PROVIDE THE DATE EMPLOYMENT ENDED
. HAVE YOU APPLIED FOR UNEMPLOYMENT? YES / NO
IF THERE IS NO REPORTED INCOME, HAVE YOU APPLIED FOR DISABILITY? YES / NO ARE YOU PLANNING ON APPLYING? YES / NO
DOES ANYONE IN YOUR HOUSEHOLD RECEIVE ANY OF THE FOLLOWING: (PLEASE PROVIDE PROOF)?
CHILD SUPPORT YES / NO AMOUNT $ __ _
ALIMONY: YES / NO AMOUNT $
CHECKING ACCOUNT NO:
YES / NO (CIRCLE)
BANK NAME:
LOCATION:
BALANCE: $
SAVINGS ACCOUNT NO:
YES / NO (CIRCLE)
BANK NAME:
LOCATION:
BALANCE: $
STOCKS, BONDS, IRA’S, 401K, CDs, ETC.
YES / NO (CIRCLE)
BANK NAME:
LOCATION:
BALANCE: $
DO YOU OWN OR CURRENTLY BUYING REAL ESTATE PROPERTY: YES / NO CITY/COUNTY: __ _
TOTAL ACREAGE:
MORTGAGE AMOUNT: $____________ DO YOU LIVE ON THE REAL ESTATE PROPERTY: YES / NO
DO YOU HAVE LIFE INSURANCE FOR YOU OR ANY DEPENDENT OVER 21 WITH A CASH OR LOAN VALUE? YES / NO (CIRCLE)
NAME OF LIFE INSURANCE CO: POLICY NO: CASH-IN VALUE: $
PERSONAL PROPERTY: YES / NO (CIRCLE ONE) LIST ALL CARS, TRUCKS, MOTORCYCLES, CAMPERS, MOBILE HOMES, ETC.
IF APPLICABLE; DO YOU RESIDE IN YOUR MOBILE HOME: YES / NO
ITEM: MAKE MODEL YEAR: OWNER: AMOUNT OWED: $ VALUE: $
ITEM: MAKE MODEL YEAR: OWNER: AMOUNT OWED: $ VALUE: $
DECLARATION: THE INFORMATION PROVIDED ABOVE IS, TO THE BEST OF MY KNOWLEDGE AND BELIEF, COMPLETE, ACCURATE AND TRUE. I AUTHORIZE THE RELEASE OF ALL INFORMATION WHICH THE UVA
MEDICAL CENTER MAY NEED TO DETERMINE WHETHER I QUALIFY FOR FINANCIAL ASSISTANCE THROUGH THE HOSPITAL’S INDIGENT CARE PROGRAM, ANY DRUG MANUFACTURER SPONSORED DRUG ASSISTANCE
PROGRAM OR ANY OTHER FEDERAL OR STATE FUNDED MEDICAL ASSISTANCE PROGRAM, INCLUDING VERIFICATION OF MY SALARY OR WAGES, THE BALANCE OF ANY BANK ACCOUNTS THAT I MAINTAIN, THE
CASH-IN VALUE OF
ANY LIFE INS. POLICY, STOCKS OR BONDS WHICH I POSSESS, AS WELL AS THE VALUE OF ANY REAL OR PERSONAL PROPERTY WHICH I OWN OR AM PURCHASING. SHOULD I BE REFERRED TO A
FEDERAL OR STATE FUNDED MEDICAL ASSISTANCE PROGRAM I AUTHORIZE THE UVA MEDICAL CENTER TO RELEASE AND OBTAIN ALL INFORMATION NEEDED TO DETERMINE ELIGIBILITY FOR THAT FUNDING. I
AGREE TO IMMEDIATELY
NOTIFY UVA WHEN MY INSURANCE (MEDICAL OR PRESCRIPTION) AND/OR INCOME CHANGES.
SIGNATURE REQUIRED
APPLICANT’S SIGNATURE: DATE:
SPOUSE’S SIGNATURE: DATE:
This application was received by a UVa Medical Center Employee: _________________________________________________________________________________ Revised 10/11
PLEASE MAIL COMPLETED FORM TO:
ATTENTION VERIFICATION DEPARTMENT
BOX 800750
CHARLOTTESVILLE, VA 22908-0750
1-866-320-9659