Financial Assistance Application

Por favor haga clic aqui para completar nuestra solicitud de asistencia financiera.


THE FOLLOWING DISCLAIMER SHOULD BE READ BY THE PATIENT OR RESPONSIBLE PARTY BEFORE COMPLETING THIS FORM.


I am requesting consideration for medical financial assistance. I understand that the information I submit is subject to verification which may include an inquiry of my credit history.


I also understand that if the information I submit is determined to be false, such a determination will result in denial for consideration.


I am aware that this is a voluntary service by University Clinical Health and it maintains exclusive rights for approval or denial. I affirm that the information provided is true and correct to the best of my knowledge.

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Phone
Party responsible for the bill*

Dependents

PLEASE LIST ALL DEPENDENTS

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Dependent #1: Legal Dependent
Dependent #2 : Legal Dependent
Dependent #3: Legal Dependent
Dependent #4: Legal Dependent
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List all other dependents' full name, age, relationship to you, employers, and whether or not they are your legal dependent.

Do you, your spouse or any of your dependents have health insurance?*
In the past 6 months, did you have health insurance?*
Was your health insurance employer‐sponsored?*
In the past 6 months, did you apply for TennCare, Medicaid, Social Security benefits, Disability benefits, and/or Victims of Crime benefits?*
In the past 6 months, did you file any legal claims (car accident/work injury)?*

Please include proof of your income (wages) with this application, such as:

Last year’s 1040 tax return, Social Security statement of benefits, disability or retirement award letter, food

stamp approval letter, unemployment benefits approval letter or other proof of government assistance in jpeg, png, pdf, word doc format.


Please include proof of your legal U.S. residency with this application, such as:

US visa, property tax statement, rental agreement, driver’s license or utility bill in jpeg, png, pdf, doc format.

Drag and drop files here or

I understand & agree that by checking this box & typing my name & date that this is my legal signature.

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