In order to determine eligibility for HCAP or - Aultman Hospital

COMPLETING THE APPLICATION

If you receive medical services at Aultman or

In order to determine eligibility for HCAP or

are seen by any Aultman employed physician

Financial Assistance, we look at your gross

and feel you qualify to receive these services

income and family size as outlined OAC

without cost or at a reduced cost to you, please

5101:3-1-07.17

complete this application and return to:

Aultman Patient Outreach

2600 Sixth St SW

Canton OH 44710

Eligibility for HCAP:

1. You must be a resident of the state of

Ohio.

2. You must be at or below 100% of the

Federal Poverty Income Guidelines.

3. Family members include you, your spouse,

and/or natural or adopted children under

the age of 18 living at home.

Financial Assistance Programs

Under the Ohio Hospital Care Assurance

Program (HCAP), Aultman offers basic,

medically necessary hospital-level services

free of charge to individuals who are

residents of Ohio and whose income is at or

This program only covers services billed by

Aultman.

below the Federal Poverty Income

These financial assistance programs do NOT

In addition to the HCAP program, Aultman

cover expenses for your non-Aultman providers

provides financial assistance (FAP) on a

(including but not limited to emergency room

sliding scale to patients who do not have

physician and radiologist).

insurance at family income levels up to four

Guidelines.

(4) times the Federal Poverty Guidelines.

4. Cannot be enrolled in Medicaid.

IMPORTANT: In order to provide you with help

Eligibility for FAP:

Even if you have insurance, as long as you

meet our income criteria, you will be

eligible for financial assistance if:

?

required to cooperate completely with our

Guidelines for FREE Care

Family

Size

Income

2016

Income

2017

eligibility for medical coverage from the State.

1

$11,880

$12,060

NOTE: The HCAP program does not cover

2

$16,020

$16,240

elective or cosmetic surgery, organ transplants,

3

$20,160

$20,420

patient convenience items, take home

4

$24,300

$24,600

You have exhausted your lifetime

pharmacy, physician and anesthesia charges.

5

$28,440

$28,780

maximum days.

AGB: No patient without insurance will be

6

$32,580

$32,960

7

$36,730

$37,140

8

$40,890

$41,320

Your insurance does not provide

coverage for the medically necessary

services you are seeking.

?

under Aultman Financial Assistance, you are

Financial Counselors in order to determine

charged more that the average patient with

For questions contact Aultman Patient Outreach office at

330-363-2200 or go to our website at .

You may also contact Aultman Orrville Hospital Patient

Outreach at 330-682-3010 or go to their website at

.

insurance.

Incomplete applications will not be

considered for financial assistance.

For each additional family member add

$4,180 for 2017.

AULTMAN and AULTMAN ORRVILLE

? Hospital ? Physician

Account Number

INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED

Check office you are visiting: ? Aultman Hospitalists ? Maternal-Fetal Medicine ? Pathology ? Surgical Associates ? Aultman Physician

Center ? Drs. Tabet, Weiner or Immesoete ? Cardiovascular Consultants ? Canton General Surgery ? Anesthesia/Pain Management ?

Canton Urology ? Dr. Michael Hopkins ? Endocrinology ? Women¡¯s Health Service ? Internal Medicine ? Dunlap Family Physicians

PATIENT NAME:

Date of Birth:

SSN (optional):

/

/

APPLICANT NAME (if not a patient):

(If the applicant is not the patient, please answer the following questions as they apply to the patient.)

STREET:

CITY:

STATE:

ZIP CODE:

PHONE NUMBER:

The following questions must be answered in order to process your application:

OFFICE USE ONLY

?

1.

Were you an Ohio resident at the time of your hospital service?

? Yes

? No

2.

Did you have health insurance other than Medicaid at the time of your service?

? Yes

? No

State of Ohio HCAP Approved ? YES ? NO

HCAP Eligibility Dates:

3.

Were you an active Medicaid/DMA recipient at the time of your service?

If yes, Medicaid recipient ID number: ____________________________

4.

Do you authorize Aultman Hospital Patient Outreach and Aultman Orrville Hospital to act

on your behalf to qualify you for the greatest amount of assistance? (To determine eligibility,

an Aultman/Aultman Orrville representative may contact you for additional information. You

may also be contacted by a third©\party organization to verify your Medicaid application or

notify you of meetings and documents that are required to complete the Medicaid process.)

? Yes

5.

? Single ? Married ? Separated (if separated, spouse¡¯s income is still required.)

6.

Are you Amish?

? No

from

to

Aultman FAP Approved

? Yes

? No

? YES ? NO

Aultman Physician FAP Approved ? YES ? NO

FAP Discount

%

Expires

? Yes

? No

Check if you are self-employed, and include your 1040 and appropriate schedule.

Please provide the following information for family members living in the home. Family members include you, your spouse, and/or natural or adopted

children under age 18. For patients under the age of 18, list the patient, the patient¡¯s natural or adoptive parent(s) (regardless of whether or not the

parent lives in the home with the patient) and the patient¡¯s siblings (natural or adoptive) who live in the home.

Name (First, Last)

Age

Relationship

to Patient

Regular Wages,

Pensions, Social

Security, SSI, V A

Benefits

Jane Doe (example)

43

Self

$200.00

How Often

weekly/

every 2 weeks/

monthly

Weekly

Type of Income

Unemployment

Total Gross Income* for

3 months prior to

service date

Total Gross Income* for

12 months prior to

service date

*Prior to Deductions

*Prior to Deductions

$2,400.00

$9,600.00

(Patient)

Total Family Size:

Total Income:

NOTE: If you or any family members have no income, you must state ¡°0¡±.

If you reported zero ¡°0¡± income, please explain below how basic food and housing needs were provided prior to the date of service:

.

By my signature below, I affirm that to the best of my knowledge the answers on this application are true. I authorize Aultman Hospital Patient Outreach and

Aultman Orrville Hospital to act on my behalf to qualify me for the greatest amount of assistance. I understand an Aultman/Aultman Orrville representative

may contact me for additional information or use a third-party organization to verify the financial information stated on this application.

Date:

Office Use Only

Applicant Signature:

Date:

Form 1549 (93353) R: 02/17

Signed:

Outreach Representative

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