Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Charity Care Application Form
Your information
Patient Name *
Date of Birth
____ / ____ / ________
Phone Number
Home Address
Household Size
Employment Status
Gross Annual Household Income
Sources of Income
Additional details
Financial Hardship Description
Applied for Medicaid or Marketplace
Please bring to your visit: supporting documentation
Total Outstanding Medical Balance
Assistance Level Requested
Accuracy Certification
Applicant Signature
Date
Charity Care Application Form template from formisoft.com. formisoft.com/intake-templates/charity-care-application