Fillable Financial Assistance Application New Application Renewal

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Financial Assistance Application New Application Renewal

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Financial Assistance Application □ New Application □ Renewal
Section I: Patient Information
Name (Last, First, Middle Initial)
Birth Date (mm/dd/yyyy)
Guarantor Number
Street Address (No P.O. Box)
City
State
ZIP Code
Email Address
Marital Status
□ Single □ Married □ Divorced □ Widow □ Other
Employment Status
□ Employed □ Self-Employed □ Unemployed
□ Retired □ Disabled □ Student
Employer Name
Employer Phone Number
Have you applied for NC Medicaid?
□ Yes □ No
If yes, what date did you apply?
If yes, what was the outcome?
□ Approved □ Denied □ Pending □ Not Eligible
Section II: Spouse / Guarantor (if patient is a minor under 18 years old) □ Spouse □ Guarantor
Name (Last, First, Middle Initial)
Birth Date (mm/dd/yyyy)
Primary Phone Number
Medical Record No.
Employment Status
□ Employed □ Self-Employed □ Unemployed
□ Retired □ Disabled □ Student
Employer Name
Employer Phone Number
Section III: Household Members
Include all dependents, adults and minors, who are members of your household. If more than 4 dependents use separate page
Full Name
Relationship
Date of Birth
Medical Record No.
1.
2.
3.
4.
Section IV: Family Income
Provide income for yourself, your spouse and all other household members (if applicable)
Income Source
Patient
Spouse/Guarantor
Dependent (18+ years old)
Wages (30 days) or Self Employment
Social Security/Disability
VA Benefits
Pension/Retirement
Dividends/Interest
Unemployment/Workers’ Compensation
Alimony
Rental Income
Other Income
Did you file income taxes? □ Yes □ No If no, please explain:
If do not have any income, please explain how you support yourself or include a letter of support, signed and dated, from the
person who is providing your daily living expenses.
I certify that all information listed is true to the best of my knowledge. I understand that fraudulent or misleading information will
make me ineligible for any financial assistance. I give permission for UNC Healthcare System and all affiliated clinics, hospitals, and
entities to verify the information provided on this application.
Patient Signature
Date (mm/dd/yyyy)
Guarantor Signature (if patient is a minor under 18 years old)
Date (mm/dd/yyyy)
Return your completed application: Submit via My UNC Chart or secure fax: 984-974-6454 or
Mail attention UNC Financial Assistance Unit, 500 Eastowne Drive 2
nd
Floor, Chapel Hill, NC 27514
For questions or assistance, call the Toll-free Financial Assistance Line 866-704-5286
Instructions for completing Financial Assistance Application
Section One: Patient Information
Name: Print your last name, first name, and middle initial.
Birth Date: Print your date of birth including the 4 digit year.
Guarantor Number: Print the guarantor number located in the top right corner of your UNC Health Care billing statement. Leave blank if
you do not know your Guarantor number.
Street Address: Clearly print the physical address where you live. Do not use P.O. Box numbers.
Primary Phone Number: Print the primary phone number where you can be reached.
Email Address: Provide your email address if you would like to receive communication by email.
Marital Status: Please √ your marital status. Select single if the patient is a minor. Select other if you are separated.
Employment Status: Please √ your employment status. If you are employed include your employer name and phone number.
NC Medicaid: Please √ if you have applied for NC Medicaid. If yes, include the date you applied and the determination.
Section Two: Spouse of Guarantor (if patient is a minor under 18 years old)
If you are married, please include your spouse’s information. If the patient is a minor, please include the patient’s guarantor (parent or
legal guardian) information.
Name: Clearly print their last name, first name, and middle initial.
Birth Date: Clearly print their date of birth including the 4 digit year.
Primary Phone Number: Print the primary phone number where they can be reached.
Section Three: Household Members
Include all dependents, adults and minors, who are listed on your tax return in the DEPENDENTS section and are still members of your
household. If no taxes were filed, document all minor dependents and adults who you financially provide more than 50% of their living
expenses.
Full Name: Please include the first name, middle initial, and last name of each dependent in your household.
Relationship: Print the dependent’s relationship to the patient.
Date of Birth: Clearly print each dependent’s date of birth including the 4 digit year.
Section Four: Family Income
Provide income for yourself, your spouse, guarantor if the patient is a minor under 18 years of age, and all household dependents over 18
years of age. Household Income Includes but is not limited to: wages (30 days), self-employment income, social security benefits, Veterans
benefits, pension, dividends, interest, Unemployment income, Workers’ compensation, alimony, and income from rental properties.
No Income: If you do not have any income source, please include a letter of support, signed and dated, from the person who is providing
your daily living expenses.
Required Documents
To ensure your application is processed timely, the documents listed below must be included with your application. Please make sure all
documents are checked prior to submitting your application. If unable to provide documents listed below, please provide written
explanation.
□ NC Residency: To verify NC Residency, provide two documents per the NC Residency requirements guideline.
□ Income: Pay stubs most recent 30 days, social security award letter, disability or unemployment benefits, a letter from employer
showing proof of income or letter of support from the person you provides you with assistance.
□ Tax Return: A copy of the most recent year Federal Tax Return – Form 1040 including all the schedules. If you do not have a copy of
your taxes you can call the IRS at 1-800-829-1040 for a free transcript.
□ Accounts: Account statements (last month) for your bank accounts, including checking, savings, money market, and retirement.
Please include all pages of the statement, including blank pages.
□ Real Estate: Provide the tax value of property other than your primary residence.
□ Other: If no taxes filed, include birth certificates or custodian documents for all minor dependents. If married, include a
marriage certificate or documentation validating marriage (joint accounts, property, etc.) If patient is deceased, include
death certificate.
□ Advocate: If you have a Patient Advocate who is assisting you with the application process, please include the name and phone
number. Providing the advocates information gives us permission to speak to the advocate on your behalf.
Name: Phone:
NC Residency Requirements
NC Residency
In order to meet North Carolina state residency requirements to be Medicaid eligible, an individual must be domiciled in North Carolina
with the intention to remain here permanently or for an indefinite period or show that he entered North Carolina to seek employment or
with a job commitment. A person is domiciled in North Carolina if North Carolina is his fixed, established, or permanent place of residence
with the intention to remain there permanently or for an indefinite period.
To verify NC residency, two documents from two of the categories below need to be provided. This means a document or proof must be
from two of the little letters below. Example: An item from c and d would be acceptable. Two documents in b are not acceptable.
Applicants who do not have two of the documents must complete and sign the declaration below that they do not have two of the
documents listed.
a. A valid North Carolina drivers’ license or other identification card issued by the North Carolina Division of Motor Vehicles.
b. A current North Carolina rent, lease, or mortgage payment receipt, two bank statements, or current utility bill in the name of the
applicant or the applicant’s legal spouse, showing a North Carolina address.
c. A current North Carolina motor vehicle registration in the applicant’s name and showing the applicant’s current North Carolina
address.
d. A document verifying that the applicant is employed in North Carolina.
e. One or more documents proving that the applicant’s home in the applicant’s prior state of residence has ended, such as closing of
a bank account, termination of employment, or sale of a home.
f. The tax records of the applicant or the applicant’s legal spouse, showing a current North Carolina address.
g. A document showing that the applicant has registered with a public or private employment service in North Carolina.
h. A document showing that the applicant has enrolled his children in a public or a private school or a child care facility located in
North Carolina.
i. A document showing that the applicant is receiving public assistance (such as Food Stamps) or other services which require proof
of residence in North Carolina. Work First and Energy Assistance do not currently require proof of NC residency.
j. Records from a health department or other health care provider located in North Carolina which shows the applicant’s current
North Carolina address.
k. A written declaration from an individual who has a social, family or economic relationship with the applicant, and who has
personal knowledge of the applicant’s intent to live North Carolina permanently, for an indefinite period of time, or residing in
North Carolina in order to seek employment or with a job commitment.
l. A current North Carolina voter registration card.
m. A document from the US Department of Veteran’s Affairs, US Military or the US Department of Homeland Security verifying the
applicant’s intent to live in North Carolina permanently or for an indefinite period of time, or that the applicant is residing in North
Carolina to seek employment or has a job commitment.
n. Official North Carolina school records, signed by school officials, or diplomas issued by North Carolina schools (including secondary
schools, colleges, universities, community colleges), verifying the applicant’s intent to live North Carolina permanently or for an
indefinite period of time, or that the applicant is residing in North Carolina to seek employment or with a job commitment.
o. A document issued by a foreign consulate verifying the applicant’s intent to live in North Carolina permanently or for indefinite
period of time, or that the applicant is residing in North Carolina to seek employment or has a job commitment.
North Carolina Residency Applicant Declaration
I (the patient), verify that I CANNOT provide two North Carolina state residency verification documents.
I hereby declare that the above information is true and accurate. I understand that this declaration form is used to help verify that I meet
North Carolina state residency requirements for UNC Health Care Financial Assistance. I understand that a false or misleading declaration
by me may result in Charity Care adjustments for which I would not otherwise have qualified, and may subject me to civil and criminal
penalties.
Patient Signature:
Date:
Street Address (No P.O. Box)
Primary Phone:
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Financial Assistance Application New Application Renewal

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Completed 20 May 2021

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