Fillable Financial Assistance MyChart Supplemental Application Form Instructions (UW Medicine)

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Financial Assistance MyChart Supplemental Application Form Instructions (UW Medicine)

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Financial Assistance MyChart Supplemental Application Form Instructions
This is the supplemental application to upload directly into MyChart. Use this supplement application ONLY if you are
ap
plying through your MyChart account for Harborview Medical Center, UW Medical Center-Montlake, UW Medical
Center-Northwest, UW Physicians and UW Neighborhood Clinics. If you are submitting by mail, fax, in person or
completing a non-English application (Amharic, Chinese, Punjabi, Russian, Somali, Spanish, Vietnamese) you must
download and complete the full Financial Assistance application on our website at uwmedicine.org/financialassistance.
Y
ou can also request an application from the location where you are seeking care.
This is an application for financial assistance (also known as charity care) at UW Medicine. Washington State requires
all hospitals to
provide financial assistance to people and families who meet certain income requirements. You may
qualify for financial assistance
based on your family size and income, even if you have health insurance. Assistance is
awarded if you meet the financial assistance
guidelines which includes your household income is 300% or less of the
federal poverty level. You can request more information or refer to our financial assistance website at
uwmedicine.org/financialassistance
.
What d oes fin anc ial assi sta nce cover ? The hospital financial assistance covers appropriate hospital-based services
provided by UW Medicine depending upon your eligibility. Financial assistance may not cover all health care costs,
including services provided by other organizations.
To process your application in MyChart, y ou m u st :
Provide us information about your family; fill in the number of family members in your household (family includes
people related by birth, marriage, or adoption who live together)
•
Provide us information about your family’s gross monthly income (income before taxes and deductions)
•
Provide documentation for family income and declare assets
•
Attach additional information if needed, for example, letters of support to validate your information
•
Submit the supplemental form on page 2 and enter additional information into MyChart
UW Medicine will uphold the confidentiality and dignity of each patient. Any information submitted for consideration
of financial assistance will be treated as protected health information under the Health Insurance Portability and
Accountability Act (HIPAA).
To process your application, you must be a registered patient with a Medical Record Number (MRN):
For Harborview Medical Center, UW Medical Center-Montlake, UW Medical Center-Northwest, UW Physicians and
UW Neighborhood Clinics call the Contact Center at 206.520.5000 to register prior to completing your application.
Harborview Medical Center
UW Physicians
UW Neighborhood Clinics
Financial Counseling
325 9th Ave; Mail Stop 359758
Seattle, WA 98104-2499
Phone 206.744.3084
FAX 206.744.5187
M-F 8:00 a.m. – 4:30 p.m.
mychart.uwmedicine.org
UW Medical Center-Montlake
UW Physicians
UW Neighborhood Clinics
Financial Counseling
1959 NE Pacific Street; Mail Stop 356142
Seattle, WA 98195-6142
Phone 206.744.3084
FAX 206.598.1122
M-F 8:00 a.m. – 4:30 p.m.
mychart.uwmedicine.org
UW Medical Center-Northwest
UW Physicians
UW Neighborhood Clinics
Financial Counseling
1550 N 115th St
Seattle, WA 98133-9733
Phone 206.744.3084
FAX 206.598.1122
M-F 8:00 a.m. – 4:30 p.m.
mychart.uwmedicine.org
If you have questions and need help completing this application, please contact the facility above where you are seeking
care. You may
obtain help for any reason, including disability and language assistance. We will notify you of the final
determination of eligibility and
appeal rights, if applicable, within 14 calendar 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.
ApplMyChart-FA-English-V1-20210327
We want to help. Please submit your application promptly! You may receive bills until we get your information.
Financial Assistance – MyChart Supplemental Application Form – Confidential
This is the supplemental application to upload directly into MyChart. Use this supplement application ONLY if you are
applying through your MyChart account for Harborview Medical Center, UW Medical Center-Montlake, UW Medical
Center-Northwest, UW Physicians and UW Neighborhood Clinics. If you are submitting by mail, fax, in person or
completing a non-English application (Amharic, Chinese, Punjabi, Russian, Somali, Spanish, Vietnamese) you must
download and complete the full Financial Assistance application on our website at uwmedicine.org/financialassistance
.
You can also request an application from the location where you are seeking care.
Please fill out all information completely. If it does not apply, answer “No” or enter “NA.” Attach additional pages if needed.
PATIENT AND APPLICANT INFORMATION
Patient First Name Patient Middle Name Patient Last Name
☐
Male
☐
Female
☐
Other (may specify ________)
Medical Record No.
(MRN) Patient Birth Date
Patient Social Security No. (optional)
Person Paying Bill (Guarantor) Relationship to Patient
Guarantor Birth Date
Guarantor Social Security No. (optional)
Mailing Address
____________________________________________________________________
_______
_____________________________________________________________
City
State Zip Code
Area Code Phone Numbers
( _____ ) ____________________
( _____ ) ____________________
Email address:
_______________________________
SCREENING INFORMATION
Do you need an interpreter? ☐ Yes ☐ No
If Yes, list preferred language:
Has the patient applied for Medicaid? ☐ Yes ☐ No May be required to apply before being considered for financial assistance
Does the patient currently have health insurance? ☐ Yes ☐ No
Does the patient receive state public services such as TANF, Basic Food, 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
FAMILY INFORMATION
List family members in your household, including yourself. “Family” includes people related by birth, marriage, or adoption who
live together.
FAMILY SIZE Attach additional page if needed
Name
Date of
Birth
Relationship to Patient
If 18 years old or older:
Employer(s) name or
source of income
If 18 years old or older:
Total gross monthly
income (before taxes):
Also applying for
financial
assistance?
Yes
No
Yes
No
Yes
No
Yes
No
ApplMyChart-FA-English-V1-20210327
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Financial Assistance MyChart Supplemental Application Form Instructions (UW Medicine)

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Completed 29 June 2021

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