FA Application – Cameron Memorial Community Hospital

Online Application

"*" indicates required fields

Welcome to your Cameron Memorial Community Hospital 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:
Most Recent Pay Stubs (last four weeks)
Last Year’s Personal & Business Tax Returns & W-2’s
Alimony/Child Support Records
Social Security Benefit Letter(s)
Unemployment Statement
Veterans Benefit Letter
Bank Statements (last two months)

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 for any additional information or documentation needed to process your application.

Do you have your proof of income documents ready?*

Yes

I will mail in or drop off my proof of income documents at Cameron Memorial Community Hospital in the next 10 days.*

The address to send or drop off your documents to is: Cameron Memorial Community Hospital, Attn: Patient Financial Services, 416 E. Maumee Street Angola, IN 46703

Yes

Patient Information

Guarantor Number

Service Dates

Name*

First Last

Date of Birth*

Address*

Street Address City State ZIP Code

What county do you live in?*

Are you a legal resident of the United States?

Yes

Social Security Number

Marital Status*

Single

Married

Divorced

Phone Number

Employer Information

Is anyone in the household employed?

Yes

Please enter the employer names and which member of the household works there for the two main sources of employment income, if applicable.

Employer Name

Above employer name is for:

Patient

Spouse

Other

Employer Name

Above employer name is for:

Patient

Spouse

Other

Insurance Information

At your service date did you have any plan, group or insurance that reimburses medical expenses?*

Yes

Insurance Company Name

Insurance Effective Date

Subscriber Name

Insurance Member ID

Insurance Group Number

The following “Authorized Representative for Health Coverage Form” is required with all Financial Assistance Applications. We have prefilled out the sections that are required, but need you to review the information and sign off so our partner, ClaimAid, can apply for health insurance coverage or other resources that may be available to cover the cost of your care.

Authorized Representative for Health Coverage Form

If you want someone to act on your behalf in applying for benefits and/or act for you on an ongoing basis, this form must be completed. Be sure to select the function(s) that the representative is being authorized to do. You can select more than one representative and choose the same or different functions. The representative may be an individual or an organization. Complete ONE form per authorized representative. Both you and your representative must sign and date this form.

Name of Representative

ClaimAid works with patients to assist with getting reimbursement for medical services with quick, accurate, and compassionate representation throughout the eligibility determination process.

Check association with applicant/recipient*

ClaimAid is an Eligibility Assistance Company.

Eligibility Assistance Company

Select the function(s) the authorized representative will do:*

ClaimAid needs to be able to apply for benefits and take care of ongoing redeterminations on your behalf.

Apply

Sign application and be interviewed. Provide all required proof of information necessary to determine eligibility for benefits. Receive the Notice of the application decision. Speak on applicant’s behalf at a hearing if the application decision is appealed.

Report changes. Attend periodic redeterminations. Receive the appointment notices and any redetermination mail-in forms. Speak on applicant’s behalf at a hearing if the application decision is appealed. Note: Do not check this function if the representative will not continue to act on recipient’s behalf after the application decision has been made.*

Ongoing

Applicant/Recipient Name

Applicant/Recipient Date of Birth

Applicant/Recipient last 4 digits of Social Security Number

Signature*

I authorize this representative to act for me in taking care of the functions and program eligibility process which I have checked above. (If applicant/recipient is medically incapable to sign authorization, provide medical documentation.) I understand that I am responsible for the information anyone acting as my authorized representative gives, including any information that may be incorrect. I also understand that if at any time I wish to stop the person(s) I chose from being my authorized representative, it is my responsibility to contact the Division of Family Resources.

Household Information

Including yourself, what is the total number of people living in your household?*

Immediate family includes the responsible party, their spouse if applicable, and all dependent children under 18 years old.

Please enter a number from 1 to 8.

Additional Household Member 1

Name*

First Last

Date of Birth*

Relationship to Patient*

Additional Household Member 2

Name*

First Last

Date of Birth*

Relationship to Patient*

Additional Household Member 3

Name*

First Last

Date of Birth*

Relationship to Patient*

Additional Household Member 4

Name*

First Last

Date of Birth*

Relationship to Patient*

Additional Household Member 5

Name*

First Last

Date of Birth*

Relationship to Patient*

Additional Household Member 6

Name*

First Last

Date of Birth*

Relationship to Patient*

Additional Household Member 7

Name*

First Last

Date of Birth*

Relationship to Patient*

Household Income Information

Please provide the total monthly gross income for each of the following categories. If none, enter 0.

Patient Monthly Employment Income*

Patient Monthly Self-Employment Income*

Patient Monthly Alimony/Child Support Income*

Patient Monthly Pension Income*

Patient Monthly Social Security Income*

Patient Monthly Dividends, Interest, Rental Income*

Patient Monthly Unemployment Insurance, Workers' Compensation Income*

Patient Monthly Veterans Benefits Income*

Patient Other Monthly Income*

This field is hidden when viewing the form

Total patient current monthly income

Spouse/Other Monthly Employment Income*

Spouse/Other Monthly Self-Employment Income*

Spouse/Other Monthly Alimony/Child Support Income*

Spouse/Other Monthly Pension Income*

Spouse/Other Monthly Social Security Income*

Spouse/Other Monthly Dividends, Interest, Rental Income*

Spouse/Other Monthly Unemployment Insurance, Workers' Compensation Income*

Spouse/Other Monthly Veterans Benefits Income*

Spouse/Other Other Monthly Income*

This field is hidden when viewing the form

Total Spouse/other current monthly income

If you are not receiving any income, please explain how you are being supported financially.

This field is hidden when viewing the form

Total monthly family income

This field is hidden when viewing the form

Total Spouse/other current monthly income

This field is hidden when viewing the form

Total monthly family Self-Employment Income

This field is hidden when viewing the form

Total family monthly Alimony/Child Support Income

This field is hidden when viewing the form

Total family monthly Pension Income

This field is hidden when viewing the form

Total family monthly Social Security Income

This field is hidden when viewing the form

Total family Monthly Dividends, Interest, Rental Income

This field is hidden when viewing the form

Total family Unemployment Insurance, Workers' Compensation Income

This field is hidden when viewing the form

Total family Veterans Benefits Income

This field is hidden when viewing the form

Total family Other Monthly Income

This field is hidden when viewing the form

Total family Other Monthly Income

Assets Information

Please provide the total balance for the following categories. If none, enter 0.

Patient Checking Accounts*

Patient Saving(s) Accounts*

Patient HSA/FSA Accounts*

This field is hidden when viewing the form

Total Patient Assets

Spouse/Other Checking Accounts*

Spouse/Other Saving(s) Accounts*

Spouse/Other HSA/FSA Accounts*

This field is hidden when viewing the form

Total Spouse/Other Assets

Expenses Information

About how much do you spend each month on the following expenses? If none, enter 0.

Housing

Auto

Insurance

Electric/Gas

Health Insurance

Medical

Fuel

Household Expenses

Credit Cards

Cell Phone

Landline

Cable TV

Other

Expense Category

Other

Expense Category

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 Stubs

Please upload last 4 weeks of paystubs for all income earners, if applicable.

Drop files here or

Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10.

Medical Insurance and/or Medicaid Card – Front & Back

Please 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

Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10.

Tax Returns & W-2's

Please upload last year’s complete income tax return & W-2 form, if applicable.

Drop files here or

Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10.

Alimony/Child Support Records

Please upload alimony/child support records, if applicable.

Drop files here or

Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10.

Unemployment Statement

Please upload unemployment statement, if applicable.

Drop files here or

Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10.

Social Security Benefit Letter

Please upload any social security benefit letter(s), if applicable.

Drop files here or

Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10.

Veterans Benefit Letter

Please upload veterans benefit letter, if applicable.

Drop files here or

Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10.

Bank Statements

Please upload the past 2 months of your bank statements from your checking and savings account(s), as well as any Health Savings, Cash App, PayPal or Venmo statements, if applicable.

Drop files here or

Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10.

This field is hidden when viewing the form

Family Total = Fees

This field is hidden when viewing the form

Family Total = Self Employement

This field is hidden when viewing the form

Family Total = Child Support or Alimony

This field is hidden when viewing the form

Family Total = SSN/Pensions

This field is hidden when viewing the form

Family Total = Dividends, interest, rental income

This field is hidden when viewing the form

Family Total = Unemployment Ins, Workers' Compensation

This field is hidden when viewing the form

Family Total = Veterans Benefits

This field is hidden when viewing the form

Family Total = Other Income

This field is hidden when viewing the form

Patient Gross Totals = Current Monthly Income

This field is hidden when viewing the form

Patient/Other Gross Totals = Current Monthly Income

This field is hidden when viewing the form

Total Family Gross Totals = Current Monthly Income

This field is hidden when viewing the form

Total Patient Assets

This field is hidden when viewing the form

Total Spouse/Other Assets

This field is hidden when viewing the form

Family Additionals

This field is hidden when viewing the form

Total Family Size

This field is hidden when viewing the form

Family Additional Total 5380

This field is hidden when viewing the form

Yearly Rate 15060

This field is hidden when viewing the form

Total 12 Month Income Div by 12

This field is hidden when viewing the form

Calculated % FPL 12 Months

Signature*

I understand that the information I provide to CMCH will be subject to verification. If necessary, I give CMCH permission to access my credit history. I also understand that CMCH may ask me for more information, if necessary to determine my eligibility, e.g. proof of assets, bank statements, HSA statements, or a denial letter issued by Medicaid. This request may be denied if I do not submit the required documentation, reserve the right to reverse any adjustment if any payment is released. I have read this application carefully and all the information I have represented is accurate and true.

Relationship to patient (if not self)

Are You Ready to Submit Your Application?*

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.

Phone

This field is for validation purposes and should be left unchanged.