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How do I fill this out?
To fill out the application properly, start by entering your personal information in the designated fields. Next, provide details about your insurance coverage and monthly income. Finally, ensure you sign and submit the application to the appropriate address.
How to fill out the Financial Assistance Evaluation Application?
1
Read through the application and guidelines carefully.
2
Fill in your personal and employment details.
3
List any applicable insurance coverages.
4
Provide accurate income and expense information.
5
Sign the application before submitting it.
Who needs the Financial Assistance Evaluation Application?
1
Uninsured individuals seeking medical assistance.
2
Residents of Illinois who have used hospital services.
3
Families in need of discounted healthcare services.
4
Patients who have financial difficulties covering medical bills.
5
Individuals applying for public aid programs like Medicaid.
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1
Open the PDF in PrintFriendly.
2
Select the text or field you want to edit.
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What are the instructions for submitting this form?
To submit the financial assistance application, ensure that you have filled out all required fields accurately. You can submit the completed form in person, by mail (P.O. Box 790024, St. Louis, MO 63179-0024), via email at patacct@bjc.org, or by fax at 314-747-6977. Make certain to submit within 240 days of the initial billing date to remain eligible for assistance.
What are the important dates for this form in 2024 and 2025?
Make sure to submit your financial assistance evaluation application within 240 days of your first bill to ensure eligibility. Keep in mind that this application can have different considerations based on services and residency.
What is the purpose of this form?
The purpose of the financial assistance evaluation form is to assess an individual's eligibility for free or discounted healthcare services. This application is crucial for those who are uninsured or underinsured and need help managing their medical expenses. By completing this form, patients can access necessary healthcare resources they might otherwise forgo due to financial constraints.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes name, date of birth, and optional details such as race and ethnicity.
- 2. Employment Information: Information pertaining to the patient's employment status and that of responsible individuals.
- 3. Insurance Coverage: Details about any applicable insurance policies related to the medical services received.
- 4. Monthly Income and Expenses: Financial information including income sources and monthly expenditures to evaluate eligibility.
- 5. Certification: A section for the patient to confirm the accuracy of the provided information.
What happens if I fail to submit this form?
Failure to submit this form may result in the inability to access financial assistance from BJC HealthCare. Delays or non-submission could mean that qualifying patients miss out on important services. It's crucial to complete and submit within the specified timeframe to benefit.
- Ineligibility for Financial Assistance: If the form is not submitted, individuals may not gain access to much-needed discounts.
- Additional Medical Debt: Without assistance, patients may face accumulating medical bills they cannot afford.
- Loss of Access to Services: Failure to submit could result in delayed or denied healthcare services.
How do I know when to use this form?
- 1. Applying for Assistance: Use this form to apply for financial aid for medical services.
- 2. Qualification for Discounts: Essential for assessing eligibility for hospital discounts.
- 3. Access to Public Programs: Necessary for patients seeking assistance through public programs like Medicaid.
Frequently Asked Question
How do I access the financial assistance form?
You can download the financial assistance form directly from our website.
What information do I need to fill out the form?
You will need personal details, insurance information, and financial data.
Is there a deadline for submitting the form?
Yes, the form should be submitted within 240 days of your first billing date.
Can I edit the PDF online before submitting?
Absolutely! Use PrintFriendly to edit any fields as needed.
How do I submit my completed application?
You can submit the form via mail, fax, or email based on the instructions provided.
What if I don't have a Social Security Number?
It's optional for free care eligibility but required for some public programs.
Can I apply for assistance if I have insurance?
Yes, you can still apply for assistance even if you have insurance.
What happens after I submit my application?
BJC HealthCare will review your application and determine your eligibility.
Is there support if I have questions about the form?
Yes, you can contact BJC HealthCare for assistance with the application.
Can I fill out the form online?
You can edit and complete the form online using PrintFriendly's tools.
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