Patient Financial Assistance Application - CARTI...Completion of this application will allow CARTI...

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Financial Counseling: Phone: 501-537-8641

Email: [email protected]

CARTI Toll-Free: 1-855-552-2784

MRN:Patient Name:Date of Birth:

Patient Financial Assistance Application

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Completion of this application will allow CARTI to review your eligibility for receiving assistance from the Patient Financial Assistance / Charity Care program. It is important that you complete this application and return it with all required documentation within ten (10) business days. If you have difficulty completing this application or you have additional questions, please contact a CARTI Financial Counselor. Submission of a completed application and required documentation does not guarantee approval for financial assistance, and you remain responsible for your account balance. Please complete all sections and submit all required documents. We may request additional documents if necessary to review and validate your application.

Patient Information

Patient’s Name:

Telephone Number: Date of Birth:

Sex: Arkansas Driver’s License Number / State ID Number:

Male Female

Social Security Number:

Primary Residence Address Line 1:

Address Line 2:

City: State: Zip Code

Home Phone Number: Mobile Phone Number:

Marital Status: Marital Status Year:

Single Married Widowed Divorced Separated

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Authorized Representative

Authorized Representative / Guardian

Same as Patient Completed by Representative/Guardian Denoted Below

Authorized Representative Name:

Telephone Number: Date of Birth:

Sex: Arkansas Driver’s License Number / State ID Number:

Male Female

Social Security Number:

Primary Residence Address Line 1:

Address Line 2:

City: State: Zip Code

Home Phone Number: Mobile Phone Number:

Marital Status: Marital Status Year:

Single Married Widowed Divorced Separated

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Household Income Sources

List All Household Members:

Full Legal Name Date of Birth Employer / School Relationship Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party

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Household Income Financial Breakdown

List Combined GROSS (Pre-Tax/Pre-Deductions) ANNUALIZED (YEARLY) Income for each Member of the Household Category:

Income Source Patient Spouse Dependents Resp. Parties Gross Salary / Wages Self-Employment Rental Self-Employment / Contract Dividends / Interest Stocks / Bonds / Investment Distributions Trust Distributions Public Assistance Social Security Unemployment Workers’ Compensation Alimony Annuity Distributions Child Support Military Family Allotments Retirement / IRA / Pension Strike Benefits Disability Food Stamps Insurance Distributions (i.e. Life)Lottery / Gambling Winnings Other: Other: Other:

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Household Expenses

List Combined ANNUALIZED (YEARLY) Expenses for each Member of the Household Category:

Expense Source Patient Spouse Dependents Resp. Parties Vision/Dental Medication Out of Pocket Child/Elderly Care Primary Residence Rent / Mortgage Other Loans Payments Property Taxes Utilities - Telephone Utilities - Electricity Utilities - Gas Utilities - Water Food Clothes Car Payment / Transportation Credit Cards Health Insurance Premiums Life Insurance Premiums Other Insurance Premiums Other: Other: Other:

Non-CARTI Outstanding Medical Bill Balances:

Source / Facility Current Balance Medical Service Owner Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party

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Household Assets - Vehicles

List Vehicles for Household:

Year Make Model Purchase Price Owner Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party

Household Assets – Depository & Cash Bearing Accounts

List Bank / Depository / Investment Accounts for Household. Include any cash on-hand or reserves over $500 held (such as in a deposit box or safe).

Bank / Depository Name Current Balance Owner Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party

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Household Assets - Property

List Property Assets for Household (Home, Trailer, Land, Boat, Camper, Non-Primary Residence):

Property Description Purchase Price Purchase Year Owner Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party Patient Spouse Dependent Responsible Party

Hardships

Please check all conditions that apply and for which you can substantiate the appropriate documentation:

You are currently homeless or were homeless within the past six (6) months. You were evicted or facing eviction or foreclosure within the past six (6) months. You received a shut-off notice from a utility company within the past one (1) month. You experienced domestic violence within the past one (1) year. You experienced the death of a family member within the past six (6) months. You experienced a fire, flood, or other natural or human-caused disaster that caused substantial damage to your primary residence within the past one (1) year. You filed for bankruptcy within the past six (6) months. You experienced unexpected increases in necessary expenses due to caring for an ill, disabled, or aging family member within the past six (6) months. You claim a child as a tax dependent who’s been denied coverage for Medicaid and CHIP within the past one (1) year.

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Questionnaire

Latest Tax Returns Filed: Latest Federal Adjusted Gross Income (AGI):

Federal State

Latest Arkansas Medicaid Application Decision Date:

Arkansas Medicaid Application Decision:

Did not Apply / Refuse to Apply Approved, Full Approved, QMB Approved, SMB Approved, Spend-Down Approved, Other: ____________________________________ Denied Due Incomplete Application / Missing Documentation Denied Due to Income Denied Due to Assets Denied Due to Look-Back Penalty / Disqualifying Transfers Denied, Other: ______________________________________

Marketplace Insurance Application Decision:

Did not Apply / Refuse to Apply Approved & Enrolled Approved, but Could not Afford Denied, Reason: ____________________________________

PRIMARY HEALTH INSURANCE POLICY

Company / Carrier Name: Member ID:

Policy Name / Type: Group ID:

SECONDARY HEALTH INSURANCE POLICY



SUPPLEMENTAL COVERAGE (Health Ministry, Cancer Policy, Etc)



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CERTIFICATION

I UNDERSTAND THAT THIS APPLICATION MAY NOT BE PROCESSED UNTIL ALL REQUIRED INFORMATION IS SUBMITTED. I UNDERSTAND THAT ADDITIONAL INFORMATION MAY BE REQUIRED TO PROCESS MY APPLICATION.

I AFFIRM THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE CARTI TO OBTAIN A COPY OF MY CREDIT REPORT IF DEEMED NECESSARY TO AID IN DETERMINING MY ELIGIBILITY FOR FINANCIAL ASSISTANCE. I ALSO HEREBY AUTHORIZE CARTI THE RIGHTS TO CONTACT ANY OF THE ABOVE LISTED EMPLOYERS, CREDITORS, BANKS, OR LISTED THIRD PARTIES FOR THE PURPOSE OF CONFIRMING MY INCOME, ASSETS, EXPENSES, AND FINANCIAL STATUS. I UNDERSTAND THAT I WILL BE DISQUALIFIED FROM APPLYING FOR CARTI FINANCIAL ASSISTANCE IN THE FUTURE IF ANY OF THE INFORMATION ON THIS APPLICATION OR ON ACCOMPANYING SUBMITTED DOCUMENTATION IS FOUND TO BE MATERIALLY FALSE, FABRICATED, ALTERED, OR A MISREPRESENTATION OF THE TRUTH.

FUTHERMORE, I AGREE TO NOTIFY CARTI OF ANY CHANGE IN MY INSURANCE AND ELIGIBILITY STATUS IF APPROVED FOR FINANCIAL ASSISTANCE.

Patient or Authorized Legal Representative Signature

Print Patient or Authorized Legal Representative Name

Relationship to Patient

Date

Application Information - Completed by Financial Counselor ONLY

Medical Record Number:

Application Submission Date:

Financial Counselor Name:

Application Review Date:

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Patient Financial Assistance Documents Checklist

Government Medical Assistance Determination

One (1) or more document required, dated within 6 months of Application Submission Date:

Arkansas Medicaid Determination Letter Marketplace Determination Letter Medicare Determination Letter Other Government Healthcare Coverage/Assistance Determination Letter

Proof of Insurance Coverage

One (1) or more document required per Healthcare Insurance or Policy denoted on the application:

Health Savings Account or Flexible Spending Account Statement Marketplace Coverage Determination Letter(s) Supplementary (Health Ministry, Cancer Policy, etc) Coverage Policy Letter(s) Medical Insurance Card(s) or Policy Coverage Letter(s) from Company

Income

Two (2) or more document required per Member of Household and/or Responsible Party, dated within 12 months of Application Submission Date:

Most Recent Federal Income Tax Return(s) and/or State Income Tax Return(s) Most Recent W-2s and 1099s Last 6 Pay Statement(s) from All Employers Social Security and Supplemental Security Income Statements or Award Letter(s) Unemployment Statement(s) Workers Compensation Statement(s) or Award Letter(s) Rental / Farm / Business Income Document(s) Retirement Income Statement(s) (i.e. IRA, Pension, 401lk, 403b, etc)

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Assets

First Item Listed Below AND One (1) or more document required per Listed Asset, dated within 12 months of Application Submission Date:

(Always Required) Account Summary Statement(s) from All Bank, Investment, and Other Depository Accounts Listed with Last 3 months of Transactions Present

Account Statement(s) from All Loan Accounts with Last 3 Months of Transactions Present Investment / Security Account Statement(s) Retirement Account Statement(s) Trust Account Statement(s) Mortgage Statement(s) for non-primary residence(s)

Expenses

Two (2) or more document required:

Medical Bills Received within Last 3 Months Credit Card Statement(s) or Summary Document(s) Bills for Rent, Electric, Gas, Telephone, or Water Received within Last 3 Months Bills from Other Living Expenses to Patient Received within Last 3 Months

Residency

One (1) or more document required:

Mortgage Statement(s) State / County Tax Bill(s) Utility Bill(s) Rent / Lease Agreement(s) or Statement(s) Deed / Title

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Identity

One (1) or more document required for the Patient and/or Authorized Representative:

Driver’s License or State ID (Not Expired) Social Security Card Birth Certificate Passports or Passport Card(s) U.S. Citizenship Identification Card(s)

Department of Homeland Security & U.S. Citizenship & Immigration Services Issued Forms, such as Permanent Resident/Resident Alien Card, Certificate of Naturalization, Certificate of Citizenship, Employment Authorization

Marriage Certificate Military ID Armed Forces Discharge Papers

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