Medical Financial Assistance
|
|
- Griffin Taylor
- 7 years ago
- Views:
Transcription
1 Medical Financial Assistance
2 YOU MAY BE ELIGIBLE FOR MEDICAL As a nonprofit health plan, Kaiser Permanente strives to help people in need of financial assistance for unforeseen medical expenses. Households that meet specific income criteria may be eligible for financial assistance for medically necessary services at Kaiser Permanente medical offices*. MEDICAL FINANCIAL ASSISTANCE (MFA) ELIGIBILITY To apply for financial assistance from this Kaiser Permanente program you must complete and submit the enclosed application and meet the following eligibility criteria: Must receive services in Kaiser Permanente Colorado service areas Must meet eligibility criteria: êêa financial award will be applied for patients meeting federal poverty levels at or below 300% Household Size Monthly Income Annual Income 1 $0 2,918 $0 35,010 2 $0 3,933 $0 47,190 3 $0 4,948 $0 59,370 4 $0 5,963 $0 71,550 5 $0 6,978 $0 83,730 6 $0 7,993 $0 95,910 Federal Poverty level (FPL) 0% - 300% 0% - 300% êê A financial award will be applied due to specific special circumstances at any income level FINANCIAL ASSISTANCE Must access services at a Kaiser Permanente medical office or from a Kaiser Permanente provider Must have ongoing medical financial assistance need Cannot have a Health Savings Account with an active balance Cannot have received a Medical Financial Assistance award within the last six months PROOF OF INCOME REQUIRED To apply, please submit photocopies of the following required documentation for all household members 18 years and older: Copies of your most recently signed federal and state tax returns for all members of your household If you did not file taxes and/or your financial situation has changed since the last filing, please submit photocopies of the following required documentation for all household members 18 years and older: Copies of two most recent paycheck stubs Copies of other documents to verify additional household income (e.g. rental income, estate income, child support, etc.) for the past two months Copy of annual award notice of Social Security Income/Social Security Disability Income or letter from unemployment office *NOTE: The Medical Financial Assistance program does not cover health plan premiums.
3 APPLICATION Please complete one application for each person applying for assistance. NOTE: If you have received medical financial assistance from Kaiser Permanente in the past, you are not eligible to re-apply until six months after your last award expired. PLEASE FILL OUT ALL INFORMATION Kaiser Permanente Health Record Identification Number: Area where you receive care: Denver/Boulder o Northern Colorado o Colorado Springs/Pueblo o Name: Date of Birth: Your Preferred Language: Primary Phone: Other Phone: Is it OK to leave messages? oyes ono Address: City, State, Zip: Personal address: If applicable, Power of Attorney/Parent Name: Power of Attorney/Parent Phone: Services Requested: Please check all that apply. Diabetic Supplies Injectable Medications Labs/X-rays/Diagnostic Testing Medical Bills Medical Office Visits Optical Services Prescription Medications Weight Management Services Other: NOTE: The Medical Financial Assistance program does not cover health plan premiums. EMPLOYMENT STATUS APPLICANT: If yes, are you self-employed? oyes ono Have you applied for Medicaid in the past two months? oyes ono ounsure Other household member: If yes, is he/she self -employed? oyes ono Other household member: If yes, is he/she self-employed? oyes ono Other household member: If yes, is he/she self-employed? oyes ono
4 APPLICATION Household Monthly Income Include income for all adult household members 18 years of age or older. All adult household members must provide financial documentation. Failure to submit complete financial documentation will delay processing of your application. Including yourself, how many people live in your household over age 18? How many people live in your household under age 18? MONTHLY INCOME APPLICANT Other Household Member Other Household Member Other Household Member Salary/Wages $ $ $ Alimony/Child Support $ $ $ Pension Income $ $ $ Rental Income from $ $ $ Second Property Social Security/SSI/SSDI* $ $ $ Unemployment Income $ $ $ Other (Please Specify) $ $ $ *SSI is Social Security Income, SSDI is Social Security Disability Income APPLICANT S AVERAGE MONTHLY MEDICAL EXPENSES Prescriptions Medical Office Visits Labs X-rays Other Medical Plan Premiums (your portion)
5 APPLICATION Financial agreement and credit report authorization You warrant the truth of the information submitted on this application and hereby authorize our employees and agents to investigate and verify any information provided to us by you. Eligibility requirements include income and existing medical expenses. By signing, you are granting permission to Kaiser Permanente to obtain your credit report from one or more consumer reporting agencies. You acknowledge receipt of a copy of this agreement and promise to pay all amounts owed, by the applicant, that are covered under its terms. Incomplete applications will result in a delay in processing. Applicant/Power of Attorney will be notified, by mail or phone, whether the application is approved or denied. Signature of Applicant/Guardian Signature of other Household Member Signature of other Household Member Signature of other Household Member
6 SUBMITTING YOUR APPLICATION Please mail your completed application with all appropriate supporting documentation to: Kaiser Permanente Medical Financial Assistance Department P. O. Box Denver, Colorado Kaiser Permanente will review your application and if we need additional information, we will get back to you within 14 business days. If you have any questions or require assistance with this application, please call or (TTY for the deaf, hard of hearing, or speech impaired: ), Monday to Friday, 8 a.m. to 5 p.m., or speak to a financial counselor or patient registration associate, in the patient registration department at your local medical office. APPEALS If your application is denied, you may appeal the decision. You may obtain a Denial Appeal Form by calling or (TTY: ), Monday to Friday, 8 a.m. to 5 p.m. Please mail your completed form to the Medical Financial Assistance department at the address listed above. You will receive a response within 30 days. ADDITIONAL INFORMATION There may be additional health care options available to you or other members of your household. Visit FindYourPLan.org to learn more about these options.
7 This section to be completed by Kaiser Permanente Additional Patient Information: SSN: Coverage type: Medicare LIS: Referred to: Total award duration: Pharmacy award amount: Case entered in HC: (signature & date) Case determination and closed in HC: (signature & date) kp.org/communitybenefit _MFABro_Feb2014
Health Charity Care Application - Requirements
HUTCHINSON FINANCIAL ASSISTANCE PROGRAM Thank you for your interest in Health s Financial Assistance Program. We strive to provide quality, affordable care for all of our patients and are committed to
More informationMEDICAID BUY-IN for Workers with Disabilities
MEDICAID BUY-IN for Workers with Disabilities April 15, 2014 1 Medicaid Buy-In for Workers with Disabilities Medicaid Buy-In Affordable health care coverage for people with disabilities who work and earn
More informationNovo Nordisk Patient Assistance Program P.O. Box 181640 Louisville, KY 40261 866-310-7549 Fax: 866-441-4190
Novo Nordisk Patient Assistance Program P.O. Box 181640 Louisville, KY 40261 866-310-7549 Fax: 866-441-4190 The Novo Nordisk Patient Assistance Program provides medication to qualifying applicants at no
More informationKAISer PerMAnenTe Medical Financial Assistance Program and Discount Payment Program
KAISer PerMAnenTe Medical Financial Assistance Program and Discount Payment Program If you need help paying for your medical services, you may be eligible for Kaiser Permanente s Medical Financial Assistance
More informationInformation About The Senior Prescription Drug Assistance Program
Information About The Senior Prescription Drug Assistance Program DHS 7225 (Rev 2/07) Important Notice This notice is intended to affirm our commitment to the Americans With Disabilities Act (ADA) and
More informationIt is our mission to provide excellence in quality and service
It is our mission to provide excellence in quality and service Date: Patient Name: MRN: For your convenience, enclosed is a Financial Assistance Application. The application is for bills acquired for services
More informationHEARING AID BANK APPLICATION
HEARING AID BANK APPLICATION The Albuquerque Speech, Language, and Hearing Center s Hearing Aid Bank (HAB) program is designed to assist people with limited resources to obtain quality hearing aids, including
More informationThe Kaiser Permanente Bridge Program Application
The Kaiser Permanente Bridge Program Application Kaiser Foundation Health Plan of Georgia, Inc. APP/CB-080500 11/08 Instructions ISTRUCTIOS: Please print clearly using a blue or black ink pen. If the question
More informationPatient Financial Assistance Application Madison Valley Medical Center and Rural Health Clinic
Patient Financial Assistance Application Madison Valley Medical Center and Rural Health Clinic Madison Valley Medical Center and Rural Health Clinic (MVMC) provides, within the limits of its resources,
More informationHousing & Human Services Department Community Acton Agency 400 South Varr Avenue Telephone: (321) 633-1951 Cocoa, Florida 32922 Fax: (321) 633-1958
Housing & Human Services Department Community Acton Agency 400 South Varr Avenue Telephone: (321) 633-1951 Cocoa, Florida 32922 Fax: (321) 633-1958 Thank you for your interest in the Brevard County Low
More information201% through 225% of FPG. 226% through 250% of FPG. 75% Adjustment. 50% Adjustment
Charity Care Policy/Procedure Patient Financial Services Policy 10 Revised February 2014 Purpose: Wyoming Medical Center prides itself in being a responsible member of this community. Our commitment to
More informationHelping you stay covered. with Kaiser Permanente
Helping you stay covered with Kaiser Permanente What s inside How do I stay covered?... 2 When do I need to enroll?... 4 What are my options?... 6 Kaiser Permanente for Individuals and Families... 8 Medi-Cal...11
More informationDO I QUALIFY? To qualify for assistance from Ribbon Riders, you must meet the following criteria:
Ribbon Riders, Inc. PO Box 952283 Lake Mary, FL 32795 407.796.7465 Thank you for contacting Ribbon Riders regarding our Breast Cancer Assistance program. Please review the attached information prior to
More information2014 CHARITY CARE GUIDELINES
2014 CHARITY CARE GUIDELINES Kaleida Health is committed to providing quality health care services at a reduced charge to eligible persons who cannot afford to pay for these services. Charity care is available
More informationKaiser Permanente and Delta Dental
Kaiser Permanente and Delta Dental Dental Program for Kaiser Permanente FEHBP Enrollees You must be a Kaiser Permanente FEHBP enrollee to participate in the dental plan. Kaiser Permanente and Delta Dental
More informationFREE CARE APPLICATION ATTACHMENT
FREE CARE APPLICATION ATTACHMENT PLEASE REMEMBER THIS IS NOT AN INSURANCE PLAN IT IS A CHARITABLE CARE PROGRAM AND THERE IS NO ESTABLISHED FUND. THERE IS NO MONEY EXCHANGED FOR SERVICES BY ANY CMC PHYSICIAN/PRACTICE.
More informationKentucky Children s Health Insurance Program FREE OR LOW COST HEALTH INSURANCE FOR CHILDREN
Kentucky Children s Health Insurance Program FREE OR LOW COST HEALTH INSURANCE FOR CHILDREN What is KCHIP? FREE OR LOW COST HEALTH INSURANCE FOR CHILDREN Created in 1997 Has served approximately 270,000
More informationUPMC Financial Assistance Application Information
UPMC Financial Assistance Application Information UPMC offers financial assistance for medical care provided by UPMC facilities and UPMC affiliated physicians to eligible individuals and families. Based
More informationStart here Tear and separate pages along the perforated edge before completing
Start here Tear and separate pages along the perforated edge before completing Medicare Plus (Cost) INDIVIDUAL ENROLLMENT REQUEST FORM INSTRUCTIONS Kaiser Foundation Health Plan of the Mid-Atlantic States,
More informationNew York Lifeline Application
New York Lifeline is a government program that provides a monthly discount on home or mobile telephone services. Only ONE Lifeline discount is allowed per household. Members of a household are not permitted
More informationOne Affordable Homeownership Unit - Adaptable Unit with Accessible Features
One Affordable Homeownership Unit - Adaptable Unit with Accessible Features Located at 100 Pacific Street near Central Square, this unit will be available, through the City s Inclusionary Housing Program,
More informationYou may go to any medical provider who accepts payment from the Department of Public Aid.
Illinois Department of Human Services Illinois Department of Public Aid Mail-In Application for Medical Benefits (Esta solicitud está disponible en español.) (This application is available in Spanish.)
More informationThe following requirements must be met before your loan application will be considered:
Student Account Services Short Term Loan Program Information Packet and Loan Application The purpose of the Short Term Loan Program is to assist students in meeting temporary short term financial needs.
More informationACA Playbook - Montana Department of Public Health and Human Services
ACA CLIENT FREQUENTLY ASKED QUESTIONS SCRIPT Please refer to this document for answers to common questions clients may have about the Affordable Care Act, eligibility, and the Federally Facilitated Marketplace.
More informationFinancial Assistance
Financial Assistance Process & Application The Ochsner Health System ( OHS ) is committed to providing financial assistance for patients with a demonstrated financial need or hardship, who have received
More informationSliding Fee Discount Application
95 East Chautauqua St., P.O. Box 168, Mayville, NY 14757 (716) 753-7107 Fax (716) 753-5367 Sliding Fee Discount Application *Discount will be effective fourteen (14) days prior to receipt of completed
More informationKAISER PERMANENTE SMALL GROUP ENROLLMENT AND CHANGE FORM HMO PLAN AND FLEXIBLE CHOICE OFFERINGS
Kaiser Foundation Health Plan of the Kaiser Permanente Insurance Mid-Atlantic States, Inc. (KFHP-MAS) Company (KPIC) 2101 East Jefferson Street One Kaiser Plaza Rockville, MD 20852 Oakland, CA 94612 INSTRUCTIONS
More informationHealthy Kids Annual Renewal Application
Healthy Kids Annual Renewal Application Application Due By: It is time to renew your Healthy Kids health care coverage. If you would like it in another language, please call (415) 777-9992. It is time
More informationApplication for Mississippi Medicaid Aged, Blind and Disabled Medicaid Programs
Application for Mississippi Medicaid Aged, Blind and Disabled Medicaid Programs This application is used for an individual, couple or child to apply for Medicaid due to age or disability. Please read each
More informationHENRY COUNTY GENERAL ASSISTANCE APPLICATION 106 N. Jackson, Mt. Pleasant, IA 52641 319-385-0790 Fax: 319-385-8016
Appointment: HENRY COUNTY GENERAL ASSISTANCE APPLICATION 106 N. Jackson, Mt. Pleasant, IA 52641 319-385-0790 Fax: 319-385-8016 Date: Name: Phone: Current Address: From: / / to / / (street) (city) (state)
More informationDC SCORES Registration Checklist
DC SCORES STUDENT REGISTRATION PACKET Dear Families, Welcome to DC SCORES! Enclosed you will find the materials necessary to enroll your child in DC SCORES for the 2013 2014 school year. Please carefully
More informationSelf-Funded Provider Manual Section 3 Member Eligibility and Benefits Determination Product Descriptions Drug Benefits and Formulary
Self-Funded Provider Manual Section 3 Member Eligibility and Benefits Product Descriptions Drug Benefits and Formulary Self-Funded Provider Manual 1 Table of Contents SECTION 3: ELIGIBILITY AND BENEFITS
More informationMedicare and Your CalPERS Health Benefits. Laurie: Welcome to Medicare and Your CalPERS Health Benefits webinar.
Date: October 21, 2015 Presenter: Jim Cale and Laurie Daniels Laurie: Welcome to Medicare and Your CalPERS Health Benefits webinar. Jim: In this webinar, we ll cover information you may need to know regarding
More informationGUIDELINES FOR DISTRICT-PAID RETIREES
GUIDELINES FOR DISTRICT-PAID RETIREES This document provides the provisions of eligibility and enrollment for district-paid retirees whose district has entered into a Participation Agreement to provide
More informationHOW TO COMPLETE THIS FORM
HOW TO COMPLETE THIS FORM For your convenience, Sharp Health plan makes this reimbursement form available for your use. All requests for reimbursement received in writing shall be processed. 1. The Member
More informationWorking While Disabled A Guide to Plans for Achieving Self-Support
Working While Disabled A Guide to Plans for Achieving Self-Support Working While Disabled A Guide to Plans for Achieving Self-Support What is a plan for achieving self-support (PASS)? A plan for achieving
More informationImmigration Fee Waivers
Education for Justice Fact Sheets By Mid-Minnesota Legal Aid and Legal Services State Support Fall 2011 Education for Justice P.O. Box 14246 St. Paul, MN 55114 e4j@mylegalaid.org Immigration Fee Waivers
More informationThank you for requesting an application for an apartment. Enclosed, please find an application package.
Dear Applicant, Thank you for requesting an application for an apartment. Enclosed, please find an application package. Please read the application carefully, complete every section, and date where indicated.
More informationPOLICY. Title: Financial Assistance (Charity Care/Uncompensated Care) Approver: Kootenai Health Board Date: 09/29/2014
Title: Financial Assistance (Charity Care/Uncompensated Care) Approver: Kootenai Health Board Date: 09/29/2014 Kootenai Health is committed to excellence in providing high quality health care services
More informationMARYLAND SENIOR PRESCRIPTION DRUG ASSISTANCE PROGRAM ENROLLMENT APPLICATION
MARYLAND SENIOR PRESCRIPTION DRUG ASSISTANCE PROGRAM ENROLLMENT APPLICATION Dear Applicant: The Maryland Senior Prescription Drug Assistance Program (SPDAP) is pleased to provide you with the enclosed
More informationFINANCIAL ASSISTANCE APPLICATION: COVER LETTER
FINANCIAL ASSISTANCE APPLICATION: COVER LETTER Thank you for choosing Children s of Alabama to provide for the healthcare needs of your child. Please find attached the forms you must complete in order
More informationApplication Form Instructions
Who qualifies for this program? To qualify, you must meet ALL of the requirements listed below: Ø My doctor has prescribed a Lilly drug for me. Ø I am a permanent, legal resident of the United States or
More informationSECTION 3 - ENROLLMENT & ELIGIBILITY
SECTION 3 - ENROLLMENT & ELIGIBILITY 3-1 INTRODUCTION Purpose and Authority Roles and Responsibilities The PCHHS PCHP Governance Committee is responsible for developing eligibility criteria and enrollment
More informationMEDICARE PART D PRESCRIPTION DRUG COVERAGE 2016
PO Box 350 Willimantic, Connecticut 06226 (860)456-7790 (800)262-4414 1025 Connecticut Ave, NW Suite 709 Washington, DC 20036 (202)293-5760 MEDICARE PART D PRESCRIPTION DRUG COVERAGE 2016 Se habla español
More informationMassHealth Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth. MassHealth Buy-In for people who are eligible for Medicare
MassHealth Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth MassHealth Buy-In for people who are eligible for Medicare IF your monthly income before taxes and deductions is below AND your assets
More informationWilliamson Medical Center Charitable Care, Prompt Payment, Uninsured/Underinsured Discount Policy
Williamson Medical Center Charitable Care, Prompt Payment, Uninsured/Underinsured Discount Policy Effective January 1, 2013 1. Policy: Williamson Medical Center is committed to provide high quality patient
More informationMERIDIAN HOSPITALS CORPORATION Patient Financial Services POLICIES AND PROCEDURES
MERIDIAN HOSPITALS CORPORATION Patient Financial Services POLICIES AND PROCEDURES DISTRIBUTION: Meridian Hospitals Corporation, Patient Financial Services & Access Services SUBJECT: IRS Regulation #130266-11
More informationIndividual Enrollment Request Form
Individual Enrollment Request Form 3800 Kilroy Airport Way, Suite 100 Long Beach, CA 90806 Please contact VillageHealth if you need information in another language or format (Braille). To enroll in VillageHealth,
More informationTHIS ENROLLMENT REQUEST FORM IS IN SECTIONS. PLEASE REMOVE THIS TAB TO SEPARATE THE SECTIONS BEFORE YOU BEGIN.
THIS ENROLLMENT REQUEST FORM IS IN SECTIONS. PLEASE REMOVE THIS TAB TO SEPARATE THE SECTIONS BEFORE YOU BEGIN. Coventry Health Care Individual Enrollment Request Form Instructions Follow these easy instructions
More informationWE CAN HELP YOU! DTE ENERGY OFFERS A LOW INCOME SELF- SUFFICIENCY PLAN (LSP)
WE CAN HELP YOU! DTE ENERGY OFFERS A LOW INCOME SELF- SUFFICIENCY PLAN (LSP) This program allows you to make affordable monthly payments based on your income. The remaining portion of your bill is paid
More informationAPPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS
Capital Advantage Insurance Company Commonwealth of Pennsylvania Edward G. Rendell, Governor APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS Application Information The information
More informationPLEASE SUBMIT ONLY ONE (1) APPLICATION PER HOUSEHOLD EVEN IF YOU ARE INTERESTED IN MORE THAN ONE (1) PROPERTY. THANK YOU.
Dear Applicant: Thank you for your recent inquiry of occupancy at a Carabetta Management Company apartment community. Due to the nature of Federal Assistance provided for these properties, we are required
More informationMedicare & Senior Advantage Guide for Retiring Physicians
Medicare & Senior Advantage Guide for Retiring Physicians Medicare Basics Medicare is a federal health insurance program that pays for hospital and medical care for: Individuals who are age 65 or older
More informationOPEN ENROLLMENT FOR HEALTH BENEFITS 2014 ADJUNCT FACULTY
OPEN ENROLLMENT FOR HEALTH BENEFITS 2014 ADJUNCT FACULTY OPEN ENROLLMENT begins Monday, August 25, 2014 from 11:30AM to 4 PM in the new pavilion. Representatives from Independence Blue Cross, Delta Dental,
More informationSUBJECT: CHARITY AND UNCOMPENSATED CARE 1 of 13 DEPARTMENT: BUSINESS OFFICE REVISED: 10/2012
REFERENCE # SUBJECT: CHARITY AND UNCOMPENSATED CARE 1 of 13 DEPARTMENT: BUSINESS OFFICE REVISED: 10/2012 CHARITY AND UNCOMPENSATED CARE Purpose To provide definition of health care assistance to eligible
More informationYou may disregard any bills sent by the hospital until a written decision is made.
Dear Patient and/or Responsible Party: Pursuant to Article II(a) of the Bylaws of South Nassau Communities Hospital, the Hospital provides care without regard to source of payment. To this end, the Hospital
More informationWorking Together to Serve the Community
Working Together to Serve the Community Main Line Health and Subsidiaries Policy No. VI. 6 Effective Date: March 17, 2016 Participating Hospitals: Lankenau Medical Center Bryn Mawr Hospital Paoli Hospital
More informationYou will need to mail or fax us copies of items that apply to your case. See the next page for a list of these items.
Getting started: Health care for children CHIP and Children s Medicaid These programs offer health-care benefits for newborns and children age 18 and younger who live in Texas. With these programs, your
More informationCHARITY CARE APPLICATION REQUIRED DOCUMENTATION CHECK LIST
CHARITY CARE APPLICATION REQUIRED DOCUMENTATION CHECK LIST Please return the items below if they apply to your situation. Theses items are required to process your application for charity care assistance.
More informationCRITERIA FOR RESIDENCY AT APARTMENTS RESIDENT SCREENING AND SELECTION PROCESS
OR CRITERIA FOR RESIDENCY AT APARTMENTS RESIDENT SCREENING AND SELECTION PROCESS I. OCCUPANCY POLICY 1. Occupancy is based on the number of bedrooms in a unit. A bedroom is defined as a space within a
More informationKane County Foreclosure Redevelopment Program. Home Buyer Application
Kane County Foreclosure Redevelopment Program Home Buyer Application To apply to purchase a home that was redeveloped under the Kane County Foreclosure Redevelopment Program Please follow these three easy
More informationYour Guide to Choosing a Kaiser Permanente Medicare Health Plan
This is an advertisement. Kaiser Permanente Senior Advantage for Federal Members (HMO) Your Guide to Choosing a Kaiser Permanente Medicare Health Plan INCREASE YOUR COVERAGE without increasing your FEHB
More informationSTAGE COACH RESIDENCES 70 STAGE COACH ROAD, CENTERVILLE
STAGE COACH RESIDENCES 70 STAGE COACH ROAD, CENTERVILLE Thank you for your interest in the Stage Coach Residences (12) apartments that are available for rental to low and moderate income households. Six
More informationPersonal Pricing Plan Application
**Attention Applicant: Tear this front page off and keep for your records.** Personal Pricing Plan Application About The Personal Pricing Plan is a needs-based scholarship fund made available through the
More informationIndividual and Family Plans Georgia. 2016 Kaiser Permanente Plan Highlights
Individual and Family Plans Georgia 2016 Kaiser Permanente Plan Highlights Important deadlines There s a deadline to apply for health care coverage, whether you apply during open enrollment or during a
More information20% DISCOUNT CARE APPLICATION
CUSTOMER ASSISTANCE 20% DISCOUNT CARE APPLICATION Through the California Alternate Rates for Energy (CARE) program, SoCalGas offers a 20 percent discount to eligible customers on their monthly gas bill.
More informationSUPPORT PATH PROGRAM INTAKE FORM PHONE: 1-855-769-7284 FAX: 1-855-298-8700
SUPPORT PATH PROGRAM INTAKE FORM PHONE: 1-855-769-7284 FAX: 1-855-298-8700 1 REQUESTED SERVICE(S) (REQUIRED) CHECK ALL BOXES THAT APPLY Benefits Investigation Prior Authorization and Appeals Support Patient
More informationApplication for Adults and Children with Long Term Care Needs
State of Alaska Department of Health and Social Services Division of Public Assistance Application for Adults and Children with Long Term Care Needs Please check the services you need: Home and Community-Based
More informationBrook Haven 7781 Crystal Brook Circle * Brooksville, FL 34601 Office (352) 397-4340 Fax (813) 925-4287 RENTAL APPLICATION
Brook Haven 7781 Crystal Brook Circle * Brooksville, FL 34601 Office (352) 397-4340 Fax (813) 925-4287 RENTAL APPLICATION Desired Community Name Desired Move-in Date / /20 Desired Apartment Size (check
More informationPlease complete the 2010 Enrollment Form and return to:
Please complete the 2010 Enrollment Form and return to: WellCare Health Plan P.O. Box 69339 Harrisburg, PA 17106-9339 If you have any questions, please contact Customer Service at 1-866-765-4385 (TTY users
More informationAPPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS
APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS 1. Please read the enclosed brochure for important information. 2. You may use this application to apply for Special Care for adults
More informationELECTION FORM California Region Group Plan
Senior Advantage Important information about this election form PLEASE READ ALL PAGES BEFORE SIGNING THIS ELECTION FORM Please type or print legibly, using a black or blue ballpoint pen, and press firmly.
More informationApplication for Subsidized Child Care
COMMONWEALTH OF PENNSYLVANIA Application for Subsidized Child Care This application may be used by families who want help in paying their child care costs. The Child Care Information Services (CCIS) agency
More informationSupplemental Security Income (SSI)
Supplemental Security Income (SSI) Contact Social Security Visit our website Our website, www.socialsecurity.gov, is a valuable resource for information about all of Social Security s programs. At our
More informationAdvocare Essence (HMO-POS)
Advocare Essence (HMO-POS) offered by Security Health Plan of Wisconsin, Inc. You are currently enrolled as a member of Advocare Essence (HMO-POS). Next year there will be some changes to the plan s costs
More informationResidency Application Information
Residency Application Information Please read the enclosed Board of Regents Articles carefully. If, after reading the articles, you feel that you are able to document that you have met the criteria, please
More informationInstructions for Family Care Leave (FCL) of Absence Application New York and New England Bargained for Employees
Instructions for Family Care Leave (FCL) of Absence Application New York and New England Bargained for Employees Please read the Instructions, the Application and the Conditions for Leave completely before
More informationHealth Benefits for Workers with Disabilities Application
Illinois Department of Public Aid Health Benefits for Workers with Disabilities Application Note: This is NOT an application for cash assistance, food stamps or enrollment in the Medicaid spenddown program.
More informationSHORT-TERM MEDICAL INSURANCE COVERAGE FOR 30, 60, OR 90 DAYS
SHORT-TERM MEDICAL INSURANCE COVERAGE FOR 30, 60, OR 90 DAYS TEMPORARY HEALTH INSURANCE COVERAGE FOR THOSE WHO ARE: ¾ Between jobs ¾ Looking for a lower cost alternative to COBRA rates ¾ Waiting for other
More informationDANA-FARBER CANCER INSTITUTE PATIENT CARE AND ADMINISTRATIVE POLICY MANUAL PATIENT FINANCIAL ASSISTANCE POLICY
DANA-FARBER CANCER INSTITUTE PATIENT CARE AND ADMINISTRATIVE POLICY MANUAL 1. Purpose PATIENT FINANCIAL ASSISTANCE POLICY This policy establishes Dana-Farber Cancer Institute s (DFCI s) commitment to a
More informationNEW JERSEY HOSPITAL CARE ASSISTANCE PROGRAM APPLICATION FOR PARTICIPATION
NEW JERSEY HOSPITAL CARE ASSISTANCE PROGRAM APPLICATION FOR PARTICIPATION Dear Applicants: To participate in the New Jersey Hospital Care Assistance program, you will need to fill out an application form
More informationHow will working affect my SSDI?
How will working affect my encourages you to return to work by offering incentives. These work incentives allow you to explore working while keeping and Medicare. In Washington State, you also have options
More informationMEMBER S NAME (LAST, FIRST, M.I.) MEMBER ID OR SSN PHONE NUMBER ( ) PHYSICAL ADDRESS (CANNOT BE A PO BOX) COUNTY OF RESIDENCE EMAIL ADDRESS
Department of Technology, Management & Budget Office of Retirement Services www.michigan.gov/ors (800) 381-5111 P.O. Box 30171 Lansing, MI 48909-7671 Insurance Enrollment/Change Request MEMBER S NAME (LAST,
More informationHealth Care Coverage APPLICATION FOR. Health Care in Pennsylvania. Easy, affordable protection for your family
Important information about health care benefits. Ask someone to read this to you. APPLICATION FOR Health Care Coverage This application may be used by families with children or by pregnant women who apply
More informationExperience Health Care that Cares About You
HOW DO I APPLY FOR FINANCIAL ASSISTANCE? 1. Obtain application form. These forms are available at each CMA practice, or by calling (607) 882-0010. 2. Complete and return the form and all of the requested
More informationThere are other Medicaid programs that require a different application from this one.
MEDICAID APPLICATION FOR Qualified Medicare Beneficiaries (QMB) Specified Low Income Medicare Beneficiaries (SLIMB) Qualified Individuals 1 (QI) Working Disabled Individuals (WDI) INFORMATION FOR THE APPLICANT
More informationREDUCE OR ELIMINATE YOUR STATE CHILD SUPPORT ARREARS!
XAMP FRIEND OF THE COURT Renae Topolewski ASSISTANT FRIEND OF THE COURT Edward V. Messing, Jr. ST. CLAIR COUNTY FRIEND OF THE COURT 31 st Judicial Circuit 201 McMorran Blvd., Room 1600 Port Huron, Michigan
More informationHarvard Pilgrim s Stride SM. (HMO) Medicare Advantage Plan. Value Rx Plus Annual Notice of Change
HP15ANOCMNEPLUS 2015 Harvard Pilgrim s Stride SM (HMO) Medicare Advantage Plan Value Rx Plus Annual Notice of Change Maine Cumberland and York Y0098_15092 Accepted Harvard Pilgrim Stride Value RX Plus
More informationHealth Insurance for Illinois Families. Rod R. Blagojevich, Governor
Health Insurance for Illinois Families Rod R. Blagojevich, Governor KC 2378KC (R-3-04) IL478-2437 KidCare and FamilyCare Plans KidCare and FamilyCare are health insurance plans for Illinois residents.
More informationAPPLICATION FOR MEDICARE SUPPLEMENT INSURANCE
301 S. Vine St. APPLICATION FOR MEDICARE SUPPLEMENT INSURANCE Urbana, IL 81801-3347 Member Assigned #: 1-800-965-4022 TTY/TDD 711 or 1-800-526-0844 (Illinois Relay) Effective Date: SECTION 1: APPLICANT(S)
More informationLee County Central Point of Coordination Application Return Application Requested By: HIPPA Yes NO. Date of Application: / / Phone: #( )- -
Lee County Central Point of Coordination Application Return Application Requested By:_ HIPPA Yes NO Date of Application: / /Phone: #()-- Name of Applicant: Last First M.I. Current Address: City State Zip
More informationMEDICARE FACTS 2014 MEDICARE AND YOUR ALCATEL-LUCENT COVERAGE
MEDICARE FACTS 2014 MEDICARE AND YOUR ALCATEL-LUCENT COVERAGE Use this guide to learn more about Medicare and how it works with your Alcatel-Lucent medical and prescription drug coverage. For Formerly
More informationFamily Shared Cost Program
Family Shared Cost Program Thank you for your interest in the CCHC Family Shared Cost Program. The FSCP is designed to provide quality, compassionate health care regardless of an individual s financial
More informationLIFELINE AND LINK-UP ASSISTANCE APPLICATION
LIFELINE AND LINK-UP ASSISTANCE APPLICATION Whether you re a first-time applicant or missed your recertification deadline, you must complete and submit a new application form. The easiest way to apply
More informationDear Homeowner, Enclosed are Guidelines and Application for the Middletown Township Home Improvement Program.
Organized December 14, 1667 Pride in Middletown TOWNSHIP OF MIDDLETOWN Department of Planning and Community Development 3 Penelope Lane Middletown, NJ 07748-2504 Tel: (732) 615-2098 (732) 615-2280 Fax:
More informationBoard of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION
Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION BROWARD COUNTY COMMUNITY ACTION AGENCY 2015 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM
More informationThese are just some of the eligibility requirements meeting these criteria does not guarantee acceptance.
BARACLUDE PATIENT ASSISTANCE PROGRAM The Baraclude Patient Assistance Program is designed to provide free medication to qualifying patients who do not have prescription drug coverage and are having a hard
More informationOhio Medicaid. A Health Care. ohio medicaid
Ohio Medicaid A Health Care Program for Ohioans with Limited Income ohio medicaid Who can Medicaid help? To qualify for Medicaid, you must meet Medicaid citizenship requirements (certain non-citizens may
More informationH O M E FOR HOMEOWNERS IN DISTRICT 3
H O M E R E H A B L O A N P R O G R A M FOR HOMEOWNERS IN DISTRICT 3 Are You Having Problems with Your Plumbing? Do You Need a New Roof? Are Your Windows Old and Seeping Air? How About Other Over Looked
More informationMALIK ACADEMY AND AL BUSTAN PRESCHOOL FINANCIAL AID/REDUCED TUITION PROGRAM
MALIK ACADEMY AND AL BUSTAN PRESCHOOL FINANCIAL AID/REDUCED TUITION PROGRAM Dear Parent/Guardian: Sending children to private school can be expensive. In order to make our school affordable to as many
More information