Fillable New Jersey Hospital Care Payment Assistance Program APPLICATION (Hackensack Meridian Pascack Valley Medical Center)

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New Jersey Hospital Care Payment Assistance Program APPLICATION (Hackensack Meridian Pascack Valley Medical Center)

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Update 05/24/2016
New Jersey Hospital Care Payment Assistance Program
APPLICATION FOR PARTICIPATION
PROOF OF IDENTIFICATION, PROOF OF INCOME, AND PROOF OF ASSETS MUST ACCOMPANY THIS APPLICATION.
SEND COPIES OF ALL REQUESTED DOCUMENTS. DO NOT SEND ORIGINAL DOCUMENTS, AS THEY WILL NOT BE RETURNED.
SECTION I – Personal Information
1. PATIENT NAME
______________________________________________ ____________________________________ ________
(Last) (First) (Ml)
SOCIAL SECURITY NUMBER
___ ___ ___ - ___ ___ - ___ ___ ___ ___
3. DATE OF APPLICATION
__________/__________/__________
Month Day Year
4. INITIAL DATE OF SERVICE
__________/__________/__________
Month Day Year
5. REQUESTED DATE OF SERVICE
__________/__________/__________
Month Day Year
6. STREET ADDRESS OF PATIENT
7. TELEPHONE NUMBER
(__ __ __) __ __ __ - __ __ __ __
8. CITY, STATE, ZIP CODE
9. FAMILY SIZE *
10. U.S.CITIZENSHIP
Yes No Pending Application
11. PROOF OF 3-MONTH RESIDENCY IN THE STATE OF NJ
Yes No
12. NAME OF GUARANTOR (If other than patient) 13. IS PT OVER 65 YEARS OLD?
Yes No CWF Included
_______________________________________________________________________________________________________________________________________
14. IS PT COVERED BY INSURANCE? Yes No
SECTION II – Assets Criteria(office use)
15. Individual Assets: ____________________________
1
6.
F
amily Assets: ____________________________
17. Asset
s Include:
A. C
ash ________________________________
B. S
avings Accounts ________________________________
C. C
hecking Accounts ________________________________
D. Ce
rtificates of Deposit / I.R.A. ________________________________
E. Equity in Real Estate (other than primary residence) ________________________________
F. Ot
her Assets (Treasury Bills, negotiable paper,
Corporate stocks and bonds) ________________________________
G. Total ________________________________
* Family size includes self, spouse, and any minor children. A pregnant woman is counted as two family
members.
Clear Form
$ 0.00
Update 05/24/2016
APPLICATION FOR PARTICIPATION (Continued)
SECTION III – Income Criteria
When determining eligibility for hospital care assistance, a spouse’s income and assets must be used for an adult; parent’s income
and assets must be used for a minor child. Proof of income must accompany this application.
Income is based on the calculation of either twelve months, three months or one month of income prior to the date of service.
Patient / Family Gross Income equals the lesser of the following:
or or
18. SOURCES OF INCOME
Weekly Monthly Yearly
A. Salary / Wages Before Deductions ________________________
B. Public Assistance ________________________
C. Social Security Benefits ________________________
D. Unemployment & Workmen’s Compensation ________________________
E. Veteran’s Benefits ________________________
F. Alimony / Child Support ________________________
G. Their Monetary Support ________________________
H. Pension Payments ________________________
I. Insurance or Annuity Payments ________________________
J. Dividends / Interest ________________________
K. Rental Income ________________________
L. Net Business income (self employed/
verified by independent source) ________________________
M. Other (strike benefits, training stipends,
military family allotment, income from ________________________
estates and trusts)
N. Total ________________________
SECTION IV – Certification By Applicant
I understand that the information which I submit is subject to verification by the appropriate health care facility and the Federal or
State Governments. Willful misrepresentation of these facts will make me liable for all hospital charges and subject to civil penalties.
If so requested by the health care facility, I will apply for governmental or private medical assistance for payment of the hospital bill.
I certify that the above information regarding my family size, income, and assets is true and correct.
I understand that it is my responsibility to advise the hospital of any change in status in regards to my income or assets.
19. Signature of Patient or Guarantor 20. Date
Last 12 Months
Last 3 Months
X4
Last 1 Month
X12
$ 0.00
Update 05/24/2016
Patient Primary Attestation
Patient Name: _______________________________ Account Number: ____________________
Date of Service: ______________ Address: _____________________________
_____________________________
Please Initial
____ I and/or my spouse attest I/we have no income and have had no income since ___/___/___ to
___/___/___
____ I and/or my spouse attest I have no assets as listed on the charity care application.
____ I and/or my spouse attest I’m homeless and have been homeless since___/___/___
____ I and/or my spouse attest I/we have no Medical Insurance to cover the outstanding amount for my
hospital services.
____ I attest that my name is ___________________________________. I cannot provide proof of
identification because: ___________________________________________________________
(State Reason)
______________________________________________________________________________
____ I and/or my spouse attest I/we have income. Our gross/cash income is $_______ and we get paid on a
______________ basis.
Frequency
____ I and/or my spouse attest I have assets on the date of service above for the amount of $__________.
____ I and/or my spouse attest I’m a resident of New Jersey and intend to keep New Jersey as my residence.
Residing at: ____________________________________________________________
____ I attest that I have not made and that I do not intend to make a claim against any third party in which
I
can
seek payment, in whole or in part, for the medical services to which this application relates
(
including,
without limitation, claims for no fault, workers compensation, homeowners, underinsured
or
uninsured
motorist insurance benefits and tort claims). I understand and agree that, if any such
claim is
made,
Hackensack Meridian Health Pascack Valley Medical Center may retract its charity
care and seek payment of all charges from me. I also
agree
to notify Hackensack Meridian Health
Pascack Valley Medical Center when a claim is
filed.
______________________________
Patient Signature
______________________________
Printed Name
______________________________
Date
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New Jersey Hospital Care Payment Assistance Program APPLICATION (Hackensack Meridian Pascack Valley Medical Center)

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Completed 9 April 2021

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