Charity Care Application Form
Review amounts, payment terms, and authorization wording for your practice before sharing.
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Charity Care Application Form
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Sign up and start customizing in minutes.
Start with the Charity Care Application Form template and tailor it to your practice. It includes 15 editable fields across 2 pages. Included questions: Patient Name, Date of Birth, Phone Number, Home Address. The full field list below shows what you will get when you add this template to your account.
Choose this template to open an editable form. Review the questions, keep only the information your practice needs, and add your branding. Preview the patient experience before sharing a link or embedding the form. Responses can be reviewed in Formisoft and exported as a PDF.
Review amounts, payment terms, and authorization wording for your practice before sharing.
What's included
- Patient Name
- Date of Birth
- Phone Number
- Home Address
- Household Size
- Employment Status
- Gross Annual Household Income
- Sources of Income
- Financial Hardship Description
- Applied for Medicaid or Marketplace
- Supporting Documentation Upload
- Total Outstanding Medical Balance
- Assistance Level Requested
- Accuracy Certification
- Applicant Signature
Who uses this template
- Nonprofit hospital charity care eligibility determination
- Community health center financial assistance applications
- Patient advocacy departments connecting patients with free care programs
- Compliance documentation for IRS 501(r) financial assistance policies
All form fields
15 fields across 2 pages. Customize any field after signing up.
How to use the Charity Care Application Form
Getting started with this template takes just a few minutes. Sign up for a Formisoft trial, then select the Charity Care Application Form from the template library. Review the included questions, customize your fields, and preview the form before sharing it.
Setup steps
- 1Choose the template. Find the Charity Care Application Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 15 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
How does Formisoft protect responses?
Formisoft provides secure form collection and a Business Associate Agreement (BAA). Your practice must review the form content, access permissions, and sharing workflow for its requirements.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 15 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
With a plan that includes automation, you can configure workflows to send forms and reminders. Appointment-based sending requires the booking event to reach Formisoft.
Does this template work on mobile devices?
Yes. The Charity Care Application Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
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