IH-WOH - Care Assurance Form

First Name *

Last Name *

Date of Birth * +

Last 4 digits of Social Security Number

Patient Account #

Date of Service +

Street Address *

City *

State *

Zip Code *

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? *

Yes

No

2. Were you eligible for Medicaid at the time of service? *

Yes

No

3. Is your total gross family income at or below the poverty guidelines? *

Yes

No

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.

Name

Age

Relationship to Patient

Total Gross Income
For 3 months prior
to hospital service*

Total Gross Income
For 12 months prior
to hospital service*

Name

Age

Relationship to Patient

Total Gross Income
For 3 months prior
to hospital service*

Total Gross Income
For 12 months prior
to hospital service*

Name

Age

Relationship to Patient

Total Gross Income
For 3 months prior
to hospital service*

Total Gross Income
For 12 months prior
to hospital service*

Name

Age

Relationship to Patient

Total Gross Income
For 3 months prior
to hospital service*

Total Gross Income
For 12 months prior
to hospital service*

Name

Age

Relationship to Patient

Total Gross Income
For 3 months prior
to hospital service*

Total Gross Income
For 12 months prior
to hospital service*

Total persons in family: *

Total gross family income for 3 months *

Total gross family income for 12 months *

*If income is $0 please include an explanation of how you are surviving.

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 *

clear

Date * +

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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