FINANCIAL ASSISTANCE APPLICATION

Important: YOU MAY BE ABLE TO RECEIVE FREE OR DISCOUNTED CARE: Completing this application will help Horizon Health determine if you can receive free or discounted services, or if you might qualify for other public programs that can help pay for your healthcare. Please submit this application to the hospital. Please note, financial Assistance is available to residents of our service area in Illinois.

I. Applicant Information

IF YOU ARE UNINSURED, A SOCIAL SECURITY NUMBER IS NOT REQUIRED TO QUALIFY FOR FREE OR DISCOUNTED CARE. However, a Social Security Number is required for some public programs, including Medicaid. Providing a Social Security Number is not required but will help the hospital determine whether you qualify for any public programs.

II. Spouse Information

III. Insurance Information

IV. Household Information

V. Optional Information

We are required to ask the following demographic information. Your response or lack thereof has no influence on financial assistance determination.

VI. Documentation Upload

The following list of documentation are required upon submission for your form to be considered complete:

  • Bank statements: Three most recent bank statements (all pages) from all accounts including savings.

AND all of the following that are applicable:

  • Applicant and spouses’ wages: Most recent check stub(s). Last 13 if paid weekly; 7 if paid biweekly.
  • Social Security/Disability/Pensions: Copy of benefit sheet showing monthly amount received.
  • Alimony/child support: Copy of court order showing the monthly amount received (or paid).
  • Farm or Self-employment income: Complete copy of tax returns including W2’s if applicable.
  • Unemployment/Workers compensation: Copy of weekly benefit amount form showing last day worked and gross benefit amount.
  • Public Assistance (cash or food stamps): Copy of notice from Medicaid showing amount received.
  • No Income: A signed letter from family or friends explaining any money or help they give you to make ends meet.

VII. Acknowledgement & Electronic Signature

By signing below, I acknowledge that my electronic signature has the same legal effect and validity as a handwritten signature. I understand that by providing my e-signature, I am affirming the information I have provided is true and correct to the best of my knowledge.

I certify that the information in this application is true and correct to the best of my knowledge. I will apply for any state, federal or local assistance for which I may be eligible to help pay for this hospital bill. I understand that the information provided may be verified by the hospital, and I authorize the hospital to contact third parties to verify the accuracy of the information provided in this application. I understand that if I knowingly provide untrue information in this application, I will be ineligible for financial assistance, any financial assistance granted to me may be reversed, and I will be responsible for the payment of the hospital bill.