SOUTHEAST GEORGIA HEALTH SYSTEM APPLICATION FOR FINANCIAL ASSISTANCE

1. Applicant / Patient Information: Name: _______________________________________________Home Phone: _________________________ Address: _____________________________________________Date of Birth: ___________________________ City, State, Zip: _______________________________________Soc Security #: _______ - _____ - _______ County: ____________________________________________Do you have Health Insurance Have you previously qualified for assistance from other health care providers? Yes Marital Status: Single Married Divorced Legally Separated

Insurance Information: ________________________________

Yes

No

No

Attach a copy of the insurance card

2. Co-Applicant / Spouse / Guarantor Information: Name:__________________________________________________

Relationship to Patient: Spouse Parent

Other

Social Security Number: _______ - _____ - _______

Marital Status: Single Married

Separated

Divorced

Guarantor’s Date of Birth: _____________________ Home Phone Number: _______________ Employer’s Name: __________________________ Work Phone: ___________________

3. Dependents / Household Members: (List the names of all members in your household and family and their relationship to you. Please check the box ( ) if you claim him/her on tax return form). If you list any children on your application that are not biological or stepchildren, you must provide legal documentation to this effect.

Full Name

Relationship to Patient

Date of Birth / / / / / / / / / /

Social Security #

4. Employer Information: Patient’s Employer: Employed Homemaker Unemployed Disabled

Retired

Spouse’s / Other Household Member’s Employer: Employed Homemaker Retired Unemployed Disabled

Employer’s Name: ________________________________

Employer’s Name: ________________________________

Address: ________________________________________

Address: ________________________________________

Job Title: _______________________________________

Job Title: _______________________________________

Length of Employment: ____________________________

Length of Employment: ____________________________

Weekly hours worked: _______ Annual Income: $______ How are you paid?  Weekly  Bi-Weekly  Month  Other

Weekly hours worked: _______ Annual Income: $______ How are you paid?  Weekly  Bi-Weekly  Month  Other

01/19/2017

Page 1

Household Income: Defined as income of all individuals who live together and typically purchase and prepare meals together. List the amount of your monthly income from all sources. If a family member or someone other than a family member provides more than 50 percent support for living expenses, please provide monthly income for the supporting individual. Please provide a copy of documentation to support each income and asset source listed.

5. Monthly Household Income Information: Give monthly income for yourself and other household members. Patient

Spouse

Wages (including tips)

Proof Needed Pay stubs and most recent Federal Income Tax 1040 Income Statement, Schedule C/E from Federal Taxes Benefit Statement for all who receive

Business Income Social Security benefits (SSA/SSI) / Disability Retirement / pension benefits Public Assistance benefits (food stamps) Veterans benefits Unemployment benefits Rental Property Income (Does anyone pay you rent?)

Benefit Statement Budget Worksheet Benefit Statement Benefit Statement Income Statement, Schedule C/E from Federal Taxes Statement

Workers’ Compensation Alimony or Child Support Payments Received Other Income: ________________________ Total Monthly Gross Income:

Court order stating amount

$

Unemployment: If you do not have income, please explain how you take care of your monthly living expenses. You may be asked to furnish a letter from the Department of Labor regarding your unemployment status.

6.

Monthly Expenses: Give information about the bills you pay every month.

Monthly Expenses Rent/Mortgage Payment Utilities Food Cable Auto Loan(s) Auto Insurance Loans Total Monthly Expenses:

Monthly Payment

Monthly Expenses Credit Cards (minimum payment) Child Support Spousal Support/Alimony Child Care Liens / Wage Garnishments Medical Bills Other:

Monthly Payment

$

Total Monthly Income (Section 5) Total Monthly Expenses (Section 6) Total Monthly Income – Total Monthly Expenses

$

7. Bank Account Balances: Attach copies of your account statements. Patient

Spouse

Financial Institution

Checking Account Balance Savings Account Balance Stocks, bonds, CD or money market Balance Other accounts: ___________________________ Total Bank Accounts:

01/19/2017

$

Page 2

8. Assets / Property: Include all property and assets that you own, including all recreation vehicles, etc. Type

Detail

Residence Vehicle #1 Vehicle #2 Vehicle #3 Land Rental Property Business Other A. Total EstimatedValue

Estimated Value (A)

Unpaid Balance (B)

Type/Year/Make Type/Year/Make Type/Year/Make Number of Acres

B. Total Unpaid Balance Estimated Value (A) – Loan Balance (B)

$

9. Additional Information: Provide information regarding the medical service in which you need assistance. I am applying for a scheduled service.

Yes

No

If yes: Who referred you for the service (doctor/other): _______________________ Type of medical service: __________________________________________ Date of scheduled medical service: __________________________________--or-Doctor’s requested timeframe: ______________________________________ I am applying because I have existing bills that I cannot pay.

Yes

No

Please list the account number(s): _______________________________________________________________

Medicaid Application Status: Have you applied for Georgia Medicaid? Yes-Awaiting Approval

Yes-Not Eligible

No (if you indicated no, please check all that apply to you below)

I am currently pregnant I am the parent or relative caretaker of dependent children under 19 years of age I am 65 years of age or older I am blind Myself, or someone within my household, has a disability Note: If you have applied for Medicaid and have not received a final determination, please contact your caseworker. 01/19/2017

Page 3

Please Read the Following Before Signing and Dating the Application Please be advised that your signature indicates that you have agreed to attach all income verification. In addition to the items requested by this application, you may attach bank statements, copies of social security checks (or letters). If there is no income, please verify how expenses are being met. It is important to explain a lack of income completely so that full consideration of your application can be made. If the guarantor/patient of the spouse is self-employed, please attach the last 2-3 months of bank statements. Additional information may be requested by the financial advocate. All documentation must be attached for full consideration. Incomplete applications will be returned. Representatives are not required to follow up with applicants who submitted incomplete applications.

Certification 1. 2. 3.

4.

I, the undersigned, certify that the completed information in this document is true and accurate to the best of my knowledge. I will apply for any and all assistance that may be available to help pay this bill. I understand the information submitted is subject to verification; therefore, I grant the permission and authorize any bank, insurance company, real estate company, financial institution and credit grantors of any kind to disclose to SOUTHEAST GEORGIA HEALTH SYSTEM all pertinent information regarding past and present accounts. I understand that financial assistance will not be granted if complete and accurate information and supporting documentation are not provided.

I, ___________________ , give permission to Southeast Georgia Health System to share information contained in this application and supporting documentation with Cooperative Healthcare Services, Inc.

_______________________________________________________ Signature Patient/Guardian

_______________________________ Date

_______________________________________________________ Signature Spouse

_______________________________ Date

Please return completed application and required documentation to: Southeast Georgia Health System Attention: Financial Assistance Department P. O. Box 1518 Brunswick, Georgia 31521 (912) 466-5000

01/19/2017

Page 4

SOUTHEAST GEORGIA HEALTH SYSTEM Supporting Documentation Requirements Financial Assistance may only be granted based on the receipt of a completed and signed Financial Assistance application along with the following documentation requirements: (Please Provide Copies Only) Note: Financial Assistance is based on a two-part test that involves income and net assets. Individuals with net assets in excess of $10,000 or families with net assets in excess of $25,000 are not eligible for scheduled financial assistance. Step 1) Verification of Identification (1 document required) – Copy Only Georgia Driver’s License

Georgia State ID Card

College/Student ID

Permanent Resident Card (Green Card)

Step 2) Verification of Residency – For applicants that do not have a current driver’s license or state ID (1 document required) – Copy Only Utility Bill with Voter Registration Mortgage Lease or Complete Name and Property Tax Bill Card Statement Address Step 3) Proof of Income – Provide documentation to support each income amount listed on application: Copies Only. Note: We may require more than one document to confirm income. W-2 from Most Employer Notarized Pay Stubs: Lat Month: Current Tax Return / Recent Tax Filing Letter Confirming (4-Weekly, 2-Biweekly, W-2 (If no taxes are Monthly Income 1-Monthly) available Amount Social Security – Alimony and /or Child Unemployment Social Security SSDI) Bank Statement Support Benefits 1099 Award Award Letter Showing Auto Documentation Letter Deposit Notarized Court *Support Notarized Food Stamps Award Cash Assistance Award Letter Stating Letter Stating Letter Letter Income Assistance to Patient Self Employed – Most Recent Tax Return – All Pages: (Last Year) Including but not Self Employed – limited to Self Employment Earnings (Schedule C from Tax Return), Schedule E from Income Statement Taxes (Rental Schedule) Step 4) Verification of Assets – Provide documentation to support each asset amount listed on application: Copies Only. Note: We may require more than one document to confirm assets. Checking Account Savings Account Mortgage Stocks Statement Last 2 months Last 2 months Statement Certificate of Deposit Money Market Reverse Mortgage Bonds Statement Statement (CD) Statement Benefit Statement Vehicle - Proof of Other Ownership

*If someone other than your spouse is providing you more than 50 percent support for living expenses, please provide the above documentation for the supporting individual.

01/19/2017

Page 5

Notice of Nondiscrimination and Language [Type the document title]Assistance Services Southeast Georgia Health System complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Southeast Georgia Health System does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Southeast Georgia Health System: 1. Provides free aids and services to people with disabilities to communicate effectively with us, such as: a. Qualified sign language interpreters b. Written information in other formats (large print, audio, accessible electronic formats, other formats) 2. Provides free language services to people whose primary language is not English, such as: a. Qualified interpreters b. Information written in other languages. If you need these services, please contact 1-866-645-5572. If you believe that Southeast Georgia Health System has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with Meredith Horne, Compliance Specialist & Civil Rights Coordinator, 2415 Parkwood Drive, Brunswick, GA 31520, Telephone number: 912-466-3241, Fax number: 912-466-7044, Email: [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator, is available to help you.

You can also file a civil rights complaint with: the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201 Telephone: 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

01/19/2017

Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-645-5572. Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-866-645-5572. 한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-866-645-5572 번으로 전화해 주십시오. 繁體中文 (Chinese) 注意：如果您使用繁體中文，您 可以免費獲得語言援助服務。請致電 1-866-645-5572 ુ રાતી (Gujarati) ચન ુ ા: જો તમે �જરાતી બોલતા હો, ગજ તો િ ન:�લ્કુ ભાષા સહાય સેવાઓ તમારા માટ� ઉપલબ્ધ છ. ફોન કરો 1-866-645-5572. Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-866-645-5572. አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-866-645-5572. ह द िं ी (Hindi)

:

ह द िं ी

1-866-6455572 Kreyòl Ayisyen (French Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-645-5572. Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-866-645-5572. ‫( م ك توب ة ال عرب ية‬Arabic) : .866-645-5572-1 . Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-866-645-5572. ‫( ن و ش ته ف ار سی‬Farsi) : . 1-866-645-5572 . Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-866645-5572. 日本語 (Japanese) 注意事項：日本語を話される場 合、無料の言語支援をご利用いただけます。1-866645-5572 。

Page 6