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

Responses are encrypted, only your team can see them, and a BAA is included.

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.

Yes. 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.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Charity Care Application Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

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