Online Application "*" indicates required fields Welcome to your Fisher-Titus Medical Center online financial assistance application! In order to process your application, we need supporting documents to verify your financial situation. Required documents include any of the following that apply to your household: Pay Stubs Bank Statements for Checking and Savings Accounts Proof of income for all income sources After reviewing your submitted application, we may reach out to assist you with additional programs and insurance options available to you. Please get an electronic copy or pictures of your documents ready before starting your application. If you submit an incomplete application, we will reach out to you via mail for any additional information or documentation needed to process your application. Patient Name* First Last Patient Date of Birth* Patient Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number* Email Marital Status* Single Married Widowed Divorced Date(s) of Hospital ServiceFrom: Date(s) of Hospital ServiceTo: Were you an Ohio resident at the time of your hospital service?* Yes No What was the patient's gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was the patient's gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.* Including yourself, what is the total number of people living in your household?*“Family” is defined as the responsible party, the responsible party’s spouse (if applicable), and all of their natural or adoptive children under 18 who live in their home.Please enter a number from 1 to 8.Additional Household Member 1 – Name* First Last Additional Household Member 1 – Date of Birth* Additional Household Member 1 – Relationship to Patient* What was Additional Family Member 1's gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 1's gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Household Member 2 – Name* First Last Additional Household Member 2 – Date of Birth* Additional Household Member 2 – Relationship to Patient* What was Additional Family Member 2's gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 2's gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Household Member 3 – Name* First Last Additional Household Member 3 – Date of Birth* Additional Household Member 3 – Relationship to Patient* What was Additional Family Member 3's gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 3's gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Household Member 4 – Name* First Last Additional Household Member 4 – Date of Birth* Additional Household Member 4 – Relationship to Patient* What was Additional Family Member 4's gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 4's gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Household Member 5 – Name* First Last Additional Household Member 5 – Date of Birth* Additional Household Member 5 – Relationship to Patient* What was Additional Family Member 5's gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 5's gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Household Member 6 – Name* First Last Additional Household Member 6 – Date of Birth* Additional Household Member 6 – Relationship to Patient* What was Additional Family Member 6's gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 6's gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Household Member 7 – Name* First Last Additional Household Member 7 – Date of Birth* Additional Household Member 7 – Relationship to Patient* What was Additional Family Member 7's gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 7's gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*If there is no income, please explain how patient is supporting self: Household Banking and Current Asset Information Please provide the total household monthly balance in each of the following categories. If none, enter 0. Patient Savings Account(s)*Patient Checking Account(s)*Patient Health Savings Account(s)*Non-Primary Residence Real Estate*Spouse/Other Savings Account(s)*Spouse/Other Checking Account(s)*Spouse/Other Health Savings Account(s)*Spouse/Other Non-Primary Residence Real Estate* Were you an active Medicaid recipient at the time of your hospital service?* Yes No If yes, please enter your Medicaid Billing Number. Did you have health insurance (other than Medicaid) at the time of your hospital service?* Yes No Insurance Company Name Insurance Company Phone Number Insurance Group Number Insurance Member ID Are these services a result of a motor vehicle accident?* Yes No Uploading Documents This section is for attaching the documents we need to fully process your application and verify the information you provided. Please include copies of all of the following that apply to your household. Pay StubsPlease upload the last 2 paystubs for all income earners, if applicable. Drop files here or Select files Max. file size: 50 MB, Max. files: 10. Tax ReturnsPlease upload your tax returns from last year, if applicable. Drop files here or Select files Max. file size: 50 MB, Max. files: 10. Other Income StatementsPlease upload any other statements you receive from income sources (Social Security, alimony/child support, unemployment, retirement/pension, etc.), if applicable. Drop files here or Select files Max. file size: 50 MB, Max. files: 10. Bank Statements for Checking and Savings AccountsPlease upload your most recent bank statements from your checking and savings accounts, if applicable. Drop files here or Select files Max. file size: 50 MB, Max. files: 10. Medical Insurance and/or Medicaid Card – Front & BackPlease attach pictures or copies of the front and back of your medical insurance or Medicaid card effective at the time of service, if applicable. Drop files here or Select files Max. file size: 50 MB, Max. files: 10. HiddenTotal Family Income 3 months prior to the date of service?HiddenTotal Family Income 12 months prior to the date of service?HiddenFamily AdditionalsHiddenTotal Family SizeHiddenFamily Additional Total 5380HiddenYearly Rate 15060HiddenTotal 12 Month Income Div by 12HiddenCalculated % FPL 12 MonthsSignature of Applicant*I certify that the above information is true and accurate to the best of my knowledge. I will apply and take any reasonable action needed to get assistance (Medicaid, Medicare, Insurance, etc.) to pay my hospital charges. Financial assistance is a source of last resort. Any other liability or possible payer will be exhausted prior to awarding assistance. I understand that this application is made so that the hospital can see if I am eligible for HCAP or financial assistance based upon defined criteria. Are You Ready to Submit Your Application?* No I’m Ready On a scale from 1-5, with 1 being HARD and 5 being EASY, how was your experience applying for Financial Assistance online?Please enter a number from 1 to 5.Great! Please do not close your browser or leave this page until you see the confirmation page.EmailThis field is for validation purposes and should be left unchanged.
