PALMETTO HEALTH
APPLICATION FOR FINANCIAL ASSISTANCE
I.
APPLICANT – IDENTIFYING INFORMATION
County of Residence_________________________ Two or more ED visits within 12 months? _______
Emergency
Non-Emergency
Date of Service _________________________________
Hospital ______________________________________________________________________________________
Applicant Name ___________________________________ Social Security No. ________________________
Date of Birth ____________ Race _______________ Sex _____ Marital Status ________________________
Telephone: Home _____________Work _____________
Mailing Address _______________________________________________________________________________
Address where you live (if different) _____________________________________________________________
How long at this address? _______ If less than 6 months, give previous address, including county
________________________________________________________________________________________________
Is applicant a minor who does not live in the home of his parents(s) ____ Yes ____ No
If yes, give parent(s) names, address, and county of residence ___________________________________
________________________________________________________________________________________________
Is the applicant a U.S. citizen? ____ Yes ____ No
II. THIRD PARTY INFORMATION ON APPLICANT
1.
Do you have any other health insurance or Medicare? ____ Yes
____ No
If yes, financial assistance is not available.
2. Does your employer offer health insurance? ____ Yes
____ No
If yes, please note employer_________________________________________________________________
3. Are you eligible for coverage via a family member (i.e. coverage on your spouse’s coverage, parent’s
coverage, etc.)? ____ Yes
____ No
If yes, please explain________________________________________________________________________
4. Have you applied for coverage via the Health Insurance Exchanges? ____ Yes
5. Is illness due to an accident? ____ Yes ____ No
____ No
If yes, what type? __________________________
Date of accident __________________ Is claim pending? ____ Yes ____ no
If work-related, give name and address of employer at time of accident ________________________
_____________________________________________________________________________________________
6. Are you pregnant or were you pregnant at admission? ____ Yes ____ No
7. Are you a former foster care child? ____ Yes ____ No
8. Are you a caretaker or relative that claims or intends to claim the person cared for on your tax return?
____ Yes ____ No
9. Have you applied for Medicaid? ____ Yes ____ No
Date Applied _______________Status of Application (if known)______________________________________
Name of Medicaid worker (if known) __________________________________________________________
10. Have you applied for hospital services through another government program? ____ Yes ____ No
If yes, check all that apply. ____ Veterans Administration ____ DHEC
____ Commission for the Blind ____ Other (specify) ________________Date Applied ______________
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III. MEMBERS OF THE APPLICANT’S FAMILY
Name
Relationship to
Date of Birth
Applicant
and/or Age
Marital Status
IV. INCOME
1.
Do you or other family members have income? ____ Yes ____ No (Income includes wages or
Salary before deductions, net receipts from self-employments, regular public assistance
Payments such as Family Independence or SSI, Social Security, Veterans benefits, pension or
Other retirement income, unemployment compensation, workmen’s compensation, child
Support or alimony, interest income, etc.)
Name of Family Member
2.
Gross Income
Frequency
Name of Source
If not working now, when was your last day of employment? __________________________
Name and address of employer: _______________________________________________________
3. Have you or anyone in your family received a lump sum payment in the past four (4)
weeks (income tax refund, insurance settlement, etc.)? ____ Yes ____ No
If yes, amount received __________________ From whom?_______________________________
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V. RESOURCES
1.
Do you or other family members own real property (home, land, buildings, life estates, mobile
homes, etc.)? ____ Yes ____ No If yes, give the following information:
Type
Owner(s)
Location
Amount Owed, if any
If jointly owned, list all owners
2.
Do you or other family members own taxable personal property (cars, trucks, boats,
Vans, mobile homes (other than homes), motorcycles, or other kind of vehicle)?
____ Yes ____ No If yes, give the following
Type
Registered Owner(s)
Year, Make and Model Amount Owed, if any
If jointly owned, list all owners
3. Do you or other family members own non-liquid assets (retirement accounts (i.e. 401K or
individual retirement accounts) or other non-liquid investments aside from property already
noted above?
____ Yes ____ No If yes, give the following
Type
Owner(s)
Location
Account Number
Amount/Value
If jointly owned, list all
owners
4. Do you or other family members own liquid assets (cash on hand, checking accounts, savings
accounts, U.S. Savings Bonds, stocks, trust funds, certificates of deposit, face value of life
insurance, etc.)? ____ Yes ____No
If yes, give the following information:
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Type
Owner(s)
Location
Account Number
Amount/Value
If jointly owned, list all
owners
VI. TRANSFER OF RESOURCES
Have you or other family members sold or given as a gift any resources in the past three (3) months?
____ Yes ____No
Type
If yes, give the following information:
Owner(s)
Location
Account Number
Amount/Value
If jointly owned, list all
owners
VII. STATEMENT OF UNDERSTANDING
I understand that my case record is confidential and no information will be released from it
unless properly authorized by me.
I certify that I have read or had read to me all the statements on this form and that the
information given is true and complete to the best of my knowledge. I understand that if I have
deliberately given any false information or have withheld any information regarding any
situation, I am liable for prosecution for fraud. By my signature, I authorize the release of any
information needed to determine my eligibility for the Financial Assistance Program.
Applicant’s/Designee’s Signature___________________________________
Witness_______________________________________________________
VIII.
Date _____________
Date _____________
ACCOUNT NOTES
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