Fillable Financial Assistance Application Form Instructions

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Financial Assistance Application Form Instructions

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Financial Assistance Application Form Instructions
This is an application for financial assistance for U.S. Anesthesia Partners (USAP) services. As part of our commitment
to provide high quality care to all patients, USAP will honor or extend financial assistance to patients who satisfy
certain requirements. The amount of assistance depends on a patient’s annual income and family size. We
understand your desire for privacy. Except for verification purposes, the information included in your application will
be treated as confidential information.
Have you qualified for financial assistance with a facility or surgeon? If yes, then you must submit a copy of the
financial assistance determination to the address below. No USAP application is required.
What does USAP financial assistance cover? Financial assistance is available to eligible patients who have received
anesthesia care that is not covered by USAP contracted medical insurance or another direct contract with USAP.
Have questions or need help completing this application? The USAP Patient Advocacy Team is available at 833-479-
0697 Monday-Friday 7:00 a.m. – 6:00 p.m. (Central). Copies of the USAP Financial Assistance Policy and Financial
Assistance Application are available online at https://www.usap.com/patient-advocacy
at no charge. Copies may also
be requested by mail at the address below.
In order for your application to be processed, you must:
Provide information about you and any responsible party (guarantor).
Provide information on your Annual Income (Note: gross income is income before taxes and deductions).
o If the patient is an adult: total gross annual income of the patient and/or any other responsible party.
o If the patient is married: total gross annual income of the patient and patient’s spouse.
o If the patient is a minor: total gross annual income of the parents/guardian, and/or any other
responsible party.
Provide proof of your Annual Income. If you have no proof of income or no income, please attach an
additional page with an explanation. Proof of income examples include:
o W-2 withholding statement
o Current pay stubs (3 months)
o Last year’s federal income tax return, including schedules if applicable
o Written, signed statements from employers or others
o Approval/denial of eligibility for Medicaid and/or state-funded medical assistance
o Approval/denial of eligibility for unemployment compensation
Sign and date the financial assistance application
Expense and asset information is not required, however you may elect to provide this information to further
demonstrate financial hardship and support your request for financial assistance.
You do not have to provide a Social Security number to apply for financial assistance. Social Security numbers are
used to verify information provided and may help speed up the process of your application. If you do not have a
Social Security number or do not wish to provide it, please mark “not applicable” or “NA.”
Mail completed application with all documentation to the address below. Be sure to keep a copy for yourself.
USAP
Attn: Patient Advocacy Team
3705 Medical Parkway, Suite 570
Austin, TX 78705
We will notify you of the final determination of eligibility and appeal rights, if applicable, within thirty (30) days of
receiving a complete financial assistance application, including documentation of income.
By submitting a financial assistance application, you give your consent for us to make necessary inquiries to confirm
financial obligations and information.
Please submit your application promptly. You may receive bills until we receive your information.
Financial Assistance Application
Please fill out all information completely. If it does not apply, write “NA.” Attach additional pages if needed.
SCREENING INFORMATION
Has the patient applied for Medicaid? □ Yes □ No
Does the patient receive public services such as TANF, SNAP, or WIC? □ Yes □ No
Is the patient currently homeless? □ Yes □ No
Is the patient’s medical care need related to a car accident or work injury? □ Yes □ No
PATIENT INFORMATION
Patient Name: ______________________________________________ Date of Birth: _________________________
Social Security Number
(optional): _____________________________________________________________________
Guarantor Name: _______________________________________ Relationship to Patient: ______________________
Guarantor Date of Birth: _____________________ Guarantor Social Security Number
(optional): __________________
Mailing Address: _________________________________________________________________________________
Phone Number: ____________________________ Email Address: _________________________________________
Service(s) and Date(s) Requested for Assistance: ________________________________________________________
Employment Status of Patient (or Guarantor if applicable):
□ Employed Full Time □ Employed Part Time □ Unemployed (how long:_____________________)
□ Self-Employed □ Student □ Disabled □ Retired □ Other (______________________)
INCOME INFORMATION
Name
Employer(s) name or source of income*
Total gross monthly income (before taxes)
Patient
Spouse
Guarantor
*Includes all wages, farm or self-employment, public assistance, social security, unemployment/worker’s compensation, retirement, strike benefits, alimony,
child support, military allotments, pensions, incomes from dividends, interest, rental property and other miscellaneous income sources.
EXPENSE INFORMATION List all monthly household expenses:
Rent/Mortgage $_______________________ Medical Expenses $_______________________
Automobiles $_________________________ Utilities $_______________________________
Other Debt/Expenses $_________________________________________ (including child support, loans, etc)
ASSET INFORMATION List any additional assets your family may have:
Current checking account balance $_______________ Current savings account balance $________________
Please check all that apply: □ Stocks □ Bonds □ 401K □ Health Savings Account(s) □ Trust(s)
□ Property (excluding primary residence) □ Own a business
PATIENT AGREEMENT
I understand that U.S. Anesthesia Partners may verify information by reviewing credit information and obtaining
information from other sources to assist in determining eligibility for financial assistance or payment plans. I affirm
that the above information is true and correct to the best of my knowledge. I understand if the financial information I
give is determined to be false, the result may be denial of financial assistance, and I may be responsible for and
expected to pay for services provided.
Patient/Guarantor Signature: _______________________________________________ Date: __________________
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Financial Assistance Application Form Instructions

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Completed 29 January 2021

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