formisoft

Charity Care Application Form

Asks about home address, household size, and employment status. Built for nonprofit hospital charity care eligibility determination.

Questions
15
Pages
2
Time
about 4 min

Includes

  • E-signature
  • File upload
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Your practice

Charity Care Application Form

Page 1 of 2 · Your information

Live preview. Tap through it like a patient.

Who it is for

  • 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

What's inside

Before you publish: Review amounts, payment terms, and authorization wording for your practice before sharing.

Page 1 · Your information

  1. Patient NameText · Required
  2. Date of BirthDate
  3. Phone NumberPhone
  4. Home AddressText
  5. Household SizeNumber

Page 2 · Additional details

  1. Financial Hardship DescriptionLong Text
  2. Applied for Medicaid or MarketplaceLong Text
  3. Supporting Documentation UploadFile Upload
  4. Total Outstanding Medical BalanceNumber
  5. Assistance Level RequestedLong Text

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Charity Care Application Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

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Questions

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.

Yes. You can add, remove, reorder, or reword any of the 15 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Patients open a secure link from an email, a text, or a QR code and complete the form on their phone, tablet, or computer before their appointment. No app download required.

Yes, on Front Desk. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Yes. The Charity Care Application Form works on any device. Most patients complete intake forms on their phone, so every template is built for small screens first.

Send it before the visit, so patients arrive ready.

Add the Charity Care Application Form to your account and make it yours in a few minutes.

Cancel anytime · BAA included

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