NewYork-Presbyterian Hospital Charity Care Application
This document provides an application for charity care at NewYork-Presbyterian Hospital. It includes instructions for filling out the application and details on eligibility requirements. Users can apply for financial assistance for medical services through this form.
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How do I fill this out?
To fill out the application, start by gathering your personal and financial information. Next, complete each section carefully, ensuring accuracy in all entries. Finally, review your application for completeness before submission.
How to fill out the NewYork-Presbyterian Hospital Charity Care Application?
1
Gather personal information including your name, date of birth, and address.
2
List your income sources and family size accurately.
3
Provide documentation supporting your income claims.
4
Review the application for any missing information.
5
Submit the completed application to NewYork-Presbyterian Hospital.
Who needs the NewYork-Presbyterian Hospital Charity Care Application?
1
Individuals seeking financial assistance for medical bills.
2
Families with low income needing healthcare support.
3
Patients without health insurance requiring hospital services.
4
Those experiencing financial hardship affecting their healthcare access.
5
Residents of New York requiring charity care services.
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What are the instructions for submitting this form?
To submit the completed charity care application, mail it to NewYork-Presbyterian Hospital Patient Financial Services, 100 Jericho Quadrangle, Suite 202, Jericho, NY 11753, Attention: George Plunkett. Alternatively, you can fax the application to (516) 801-8504. Ensure all supporting documents are included and contact the hospital for any specific submission inquiries.
What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, submit your applications promptly to avoid delays. The hospital recommends submitting applications as soon as you receive a bill. Keep an eye on any changes in eligibility dates that may affect your application.
What is the purpose of this form?
The purpose of the charity care application is to provide financial assistance to patients who cannot afford medical services. It allows individuals to disclose their income levels and family size to determine eligibility for assistance. This application ensures that no patient is denied necessary medical care due to financial hardship.
Tell me about this form and its components and fields line-by-line.
- 1. Patient's Name: Fields for the patient's last, first, and middle initial.
- 2. Date of Birth: To determine the patient's age and eligibility.
- 3. Address: Includes number, street, apartment, city, state, and zip code.
- 4. Telephone No: To contact the applicant for any follow-up.
- 5. Occupation: Current job title of the applicant.
- 6. Employer: The name of the employer where the applicant works.
- 7. Income: Details of the combined income for the household.
- 8. Family Size: Number of family members living in the household.
- 9. Supporting Documentation: List of documents needed to verify the provided information.
- 10. Signature: Where the applicant must sign to affirm the information is correct.
What happens if I fail to submit this form?
If the application is not submitted, the patient may face collection actions for unpaid medical bills. It's crucial to apply to avoid unnecessary charges and complications. Failing to submit means you will not receive possible financial assistance.
- Incurring Debt: Not applying may lead to accumulating debt from medical services.
- Service Denial: Patients without applied financial assistance may be denied necessary services.
- Collection Actions: Failure to apply could result in aggressive collection actions by the hospital.
How do I know when to use this form?
- 1. Utilizing Charity Care: When you cannot afford bills from medical services.
- 2. Low Income Households: For families experiencing financial difficulties.
- 3. Uninsured Patients: Those seeking care without health insurance coverage.
Frequently Asked Question
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You can download your edited PDF, but saving is not available currently.
Is it easy to fill out the form for charity care?
Yes, the form is user-friendly and easy to complete with clear sections.
What types of income do I need to report?
Report all sources of income such as wages, self-employment, and assistance.
Can I share my completed application with others?
Absolutely, you can share your PDF through various options provided.
How many times can I submit this application?
You can submit the application as many times as needed during the billing process.
Is there support if I have questions about filling out the form?
Yes, you can contact the hospital's financial services for assistance.
What should I do if my income changes?
If your income changes, you should update your application accordingly.
How do I verify my application status?
You can check your application status by contacting the Patient Financial Services.
What happens if I miss the submission deadline?
It's best to submit the application as soon as possible to avoid any issues.
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