The Illinois Office of Attorney General (OAG) final rule on financial assistance requires that Illinois hospitals must develop a financial assistance application form that conforms to the parameters of the rule. The form should be in English as well as any other language that is the primary language of at least 5% of the patients serviced by the hospital. It was mandated by January 1, 2014. The Financial Assistance Application Form shall include the following:
1. The following opening statement:
Important: YOU MAY BE ABLE TO RECEIVE FREE OR DISCOUNTED CARE: Completing this application will help ___________________ Hospital determine if you can receive free or discounted services or other public programs that can help pay for your healthcare. Please submit this application to the hospital.
IF YOU ARE UNINSURED, A SOCIAL SECURITY NUMBER IS NOT REQUIRED TO QUALIFY FOR FREE OR DISCOUNTED CARE. However, a Social Security Number is required for some public programs, including Medicaid. Providing a Social Security Number is not required, but will help the hospital determine whether you qualify for any public programs.
Please complete this form and submit it to the hospital in person, by mail, by electronic mail, or by fax to apply for free or discounted care within 60 days following the date of discharge or receipt of outpatient care.
Patient acknowledges that he or she has made a good faith effort to provide all information requested in the application to assist the hospital in determining whether the patient is eligible for financial assistance.
(OAG has indicated that nothing prohibits a hospital from providing additional information regarding the staff member or hospital department collecting the form.)
2. Patient Information, limited to:
- Name, date of birth, address;
- Whether patient was an Illinois resident when care was rendered by the hospital;
- Whether patient was involved in an alleged accident;
- Whether patient was a victim of an alleged crime;
- Social Security Number (not required if you are uninsured);
- Telephone number or cell phone number; and
- Email address.
In cases in which a spouse or partner is the patient’s guarantor or in which a parent or guardian is guarantor for a minor, include the name, address and telephone number of the guarantor.
3. Family/Household Information, limited to:
- Number of persons in the patient’s family/household;
- Number of persons who are dependents of the patient; and
- Ages of patient’s dependents.
4. Patient’s family income and employment information, limited to:
- Whether patient or patient’s spouse or partner is currently employed;
- If patient is a minor, whether patient’s parents or guardians are currently employed;
- If patient or patient’s spouse or partner is employed, name, address and telephone number of all employers;
- If minor patient’s parents or guardians are employed, name, address and telephone number of all employers;
- If patient is divorced or separated or was a party to a dissolution proceeding, whether the former spouse or partner is financially responsible for patient’s medical care per the dissolution of separation agreement;
- Gross monthly family income, including cases in which a spouse or partner is guarantor for the patient or in which a parent or guardian is guarantor for a minor, from sources, such as:
- Wages, self-employment, unemployment compensation
- Social Security, Social Security disability
- Veterans’ pension, veterans’ disability, private disability, workers’ Compensation
- Temporary Assistance for Needy Families (TANF)
- Retirement income
- Child support, alimony or other spousal support
- Other income; and
- Documentation of family income from paycheck stubs, benefit statements, award letters, court orders, federal tax returns or other documentation provided by the patient.
5. Insurance/benefit information, including but not limited to:
- Health insurance;
- Medicare, Medicare Part D, Medicare supplement;
- Medicaid; and
- Veterans’ benefits.
6. Asset and estimated asset value information, limited to:
- Checking, savings;
- Stocks, certificates of deposit, mutual funds;
- Automobiles or other vehicles;
- Real property; and
- Health savings/Flexible Spending Account.
7. Monthly expense information and estimated expense figures, limited to:
- Housing, utilities, food;
- Child care;
- Medical expenses; and
- Other expenses.
8. Certification Statement:
I certify that the information in this application is true and correct to the best of my knowledge. I will apply for any state, federal or local assistance for which I may be eligible to help pay for this hospital bill. I understand that the information provided may be verified by the hospital, and I authorize the hospital to contact third parties to verify the accuracy of the information provided in this application. I understand that if I knowingly provide untrue information in this application, I will be ineligible for financial assistance, any financial assistance granted to me may be reversed, and I will be responsible for the payment of the hospital bill.
Patient or Applicant Signature and Date