NYS Uniform Hospital Financial Assistance Application

Financial Assistance Application

You may be eligible for hospital financial assistance to pay your bills if you are uninsured, if your insurance is exhausted, or if you have health insurance but have proof of paid medical expenses totaling more than 10% of your income. Completing this form will start your request for hospital financial assistance. This form is used by all hospitals in New York State. HSS may also use this form in New Jersey, Connecticut, and Florida.

1. Patient Name (complete information that is applicable)

Patient Name (First, Middle, Last) *This question is required.

Date of Birth (mm/dd/yyyy) *This question is required.

Street Address *This question is required.

Apartment/Unit #

City *This question is required.

State *This question is required.

Zip *This question is required.

Contact Phone Number

Parent/Guardian or Lawful Representative Name (if patient is a minor child or an incapacitated adult)

Email Address (if any) *This question is required. This question requires a valid email address.

2. Family Information
Please list below all family members in your household. Your household includes yourself, your spouse or domestic partner, and any children or other dependents. For example, this would include everyone listed on the same tax return.

Gross income means your income before taxes are deducted.

Gross income can consist of work earnings (wages, salaries, tips, earnings from selfemployment), unearned income (social security, disability, and unemployment benefits), contributions (funds from family or friends), and other sources of income (temporary assistance and supplemental security income).

Space Cell	Full Name	Relationship	Total Gross Income (Current)
1.	Full Name	Relationship	Total Gross Income (Current)
2.	Full Name	Relationship	Total Gross Income (Current)
3.	Full Name	Relationship	Total Gross Income (Current)
4.	Full Name	Relationship	Total Gross Income (Current)
5.	Full Name	Relationship	Total Gross Income (Current)
6.	Full Name	Relationship	Total Gross Income (Current)
7.	Full Name	Relationship	Total Gross Income (Current)
8.	Full Name	Relationship	Total Gross Income (Current)

The hospital may request you submit documentation as proof of income; examples of documentation might include a pay stub, a letter from your employer if applicable, or Form 1040.

3. Health Insurance Status

Do you have any form of health insurance, including Medicaid, Medicare, or private insurance through your employer or purchased on your own? *This question is required.

Would you like assistance in applying for any of these programs?

Underinsured patients: people with insurance and high medical expenses. If you have insurance, please provide an estimate of the medical bills you paid in the past 12 months. The hospital may request you submit documentation as proof of paid medical expenses. This question requires a valid currency format.

4. Please upload the following information for household income verification:

Pay stubs from the most current available three (3) month period
Oral or written income verification from public assistance agencies
Flexible Spending Account or Health Care Savings Account election information and balance
Form approving or denying unemployment compensation
Bank account or investment statements
SSI Benefit Statement or Benefit Determination
Self-Attestation

Applicants need not provide each item if the information is not available.

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5. Patient/Responsible Party: If not the patient, list the name of the person signing the form and their authority to sign on behalf of the patient (e.g., spouse, parent, legal representative). *This question is required.

I understand that the information I submit may be subject to verification from external sources. I certify that the information is true and complete to the best of my knowledge.

6. Signature

Type your Full Name *This question is required.

Relation to patient

Date This question requires a valid date format of MM/DD/YYYY.

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