Financial Assistance Application
Financial Assistance Application
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Applicant Letter
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General Information
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Applicant Employment
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Spouse Employment
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Insurance Information
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Household members
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Assets
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Patient Certification
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Review Your Entry
Dear Applicant:
Mercyhealth is proud to partner with patients who are experiencing financial difficulty. You may be eligible for Mercyhealth’s Financial Assistance (“Community Care”) Program if you are unable to pay your bill in full. We will accept your application for up to two hundred forty (240) days following the first billing statement for your care. You may also apply for this assistance through your Mercyhealth MyChart App. When the fully completed application is received, we will evaluate your qualifications for partial or full financial assistance and let you know whether your application has been approved.
You may be required to meet with a Mercyhealth Patient Financial Counselor (PFC), or a Customer Service Representative (CSR) to complete this process. Mercyhealth will help determine your eligibility for any government, or other financial resources. You also may be required to apply for Medicaid or other Health Insurance through the Marketplace at www.healthcare.gov or by calling (800) 318-2596. We can assist in completing the application and answer any questions you may have.
Mercyhealth’s Community Care Program applies only to medically necessary services provided by Mercyhealth.
Community Care approval decisions are based upon your household’s annual gross income. In order to assess your situation, you must complete the application in its entirety, including signature(s).
You must also provide Income documentation for all members of the household that shall include any one of the following:
Copy of W-2 forms and/or Federal Income Tax Return (1040 or 1099 forms) for the most recent tax year, including all schedules filed with the original return.
Copies of the two most recent payroll voucher/check stubs from all jobs held in the current year, showing your year to date income.
Documentation of fixed income (Social Security, Veterans, Pensions, Unemployment Compensation, Child Support/Alimony, W2 payments, Disability).
Written income verification from an employer if paid in cash.
You must also provide the documents requested below. Your application may be delayed or denied if any required documents are not included. If you cannot provide an applicable document, please attach a written explanation.
1. Identification: Please provide one of the following:
□ Government-issued photo ID, if available (e.g., State Driver’s License, State Identification Card, Passport)
□ Other official form of identification
2. Proof of Illinois or Wisconsin Residency: If you did not produce a current Illinois or Wisconsin Driver’s License, or Identification Card for item #1 above, please provide at least one of the following documents, in your name:
□ Recent residential utility bill
□ Lease agreement
□ Vehicle registration card
□ Voter registration card
□ Current mail addressed to applicant from the government or other credible source
□ Letter from homeless shelter verifying your residency
□ Statement from family member of patient who resides at the same address and presents verification of residency
3. Assets: Please provide the following documents, if applicable:
□ Most recent statement for all checking, savings, and/or credit union accounts
□ Information regarding value of, and income received from, owned properties (buildings/land) other than primary residence
□ Other investment information (bonds, stocks, etc.,) other than the amounts held in, but not distributed from, IRA/401k retirement and 529 college savings accounts
Presumptive Eligibility:
If you meet certain criteria, you may be presumptively eligible to receive financial assistance without completing a financial assistance application. If any of the following apply, please provide the requested supporting documentation for our review.
Failure to complete the application or submit any of the required documentation could delay the processing of your application. If you have any questions, please contact Mercyhealth’s Customer Service at (866) 269-7115 or (800) 987-4170. We look forward to assisting you.
Mercyhealth respects the confidentiality and dignity of its patients and understands that applying for Financial Assistance may be a sensitive issue. All application information is subject to Mercyhealth’s privacy practices.
Homeless Shelter address (if applicable)
Homeless Shelter phone number (if applicable)
Homeless Shelter phone number (if applicable)
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