I believe I am eligible for free medical care based on the guidelines of the HCAP Program and would like to begin the application process. Please answer the questions below
1. Were you an Ohio resident at the time of your service? *
2. Were you eligible for Medicaid at the time of service? *
3. Is your total gross family income at or below the poverty guidelines? *
Please provide the following information for all of the people in your immediate family who live in your home. For purposes of HCAP, family is defined as the patient, the patient’s spouse, and all of the patient’s children under age 18 (natural or adoptive) who live in the patient’s home. **If the patient is under the age of 18, the family shall include the patient, the patient’s natural or adoptive parent(s) (even if the parent does not live in the child’s home), and the parent’s other children under 18 (natural or adoptive) who live in the patient’s home.
I certify that I have completed the application for hospital care assurance data. I hereby declare under penalty of perjury (28 USC Section 1746) that the foregoing information is true and correct. I understand that further information may be requested of me.
Signature *
Available Assistance
Under Ohio law you may be eligible to receive basic, medically necessary hospital services without charge if you are an Ohio resident and your income is at or below the current federal poverty guidelines shown below.
Family Size Yearly Gross Income Guideline
1 $14,580
2 $19,720
3 $24,860
4 $30,000
5 $35,140
6 $40,280
7 $45,420
8 $50,560
For families with more than eight members, add $5,140 for each additional member. *A family shall include the patient, (or parents of minor patient) their spouse, and all their children, natural or adoptive under the age of 18 who live in the home.
Please Note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.
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