Online Application "*" indicates required fields Welcome to your Firelands Health online financial assistance application! You must provide proof of income such as: a copy of your W2, payroll stubs from 3 months prior to the date of service with year-to-date gross income, Social Security/Disability income, pension income, Unemployment, VA benefits, Worker Compensation and other sources of income. If you have no means of financial support, we will ask how you are meeting your daily living needs. Please get an electronic copy or pictures of your income 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. The following file types are permitted when uploading supporting documents. Images: .jpg, .jpeg, .png, .gif, .ico Documents: .pdf (Portable Document Format; Adobe Acrobat), .doc, .docx (Microsoft Word Document), .odt (OpenDocument Text Document), .xls, .xlsx (Microsoft Excel Document), .psd (Adobe Photoshop Document)Do you have your proof of income documents ready?* Yes No I will mail in or drop off my proof of income documents at Firelands Regional Medical Center in the next 10 days.*The address to send or drop off your documents to is: 1111 Hayes Avenue, Sandusky, OH 44870. Yes Household Members Information Including yourself, what is the total number of people in your immediate family?*Immediate family is defined as patient, patient’s spouse and all the patient’s children under 18 (natural and adoptive) who live in the patient’s home. If the patient is under age 18, the family shall include the patient, the patient’s natural or adoptive parent(s) and the parent(s) children under 18 (natural or adoptive) who live in the patient’s home.Please enter a number from 1 to 10.PatientName* First Last Date of Birth*Address* Street Address City State ZIP / Postal Code Phone Number*Are you a citizen of the United States? Yes No At your time of service were you a legal permanent Ohio Resident? Yes No Additional Household Member 1Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 2Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 3Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 4Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 5Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 6Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 7Name* First Last Date of Birth*Relationship to Patient*Is the patient also the responsible party for the accounts?* Yes No If no, who is the responsible Party/Applicant?* First Last Household Income InformationDo you or any members of your immediate family receive income from any sources?*Income sources = Social Security/Disability income, Pension income, Unemployment, VA benefits, Worker Compensation, Self- employment, Rentals, Alimony, Child Support, 401/IRA withdraws and other sources of income. Yes No If no, please explain how you are being supported financially.* Insurance InformationAt your service date did you have any plan, group or insurance that reimburses medical expenses?* Yes No Insurance Company NameInsurance Group NumberInsurance Member IDWere you an active Medicaid recipient at the time of your hospital service, or on Disability?* Yes No Please provide the following information for each account you are responsible for that should be considered on this application.Account NumberDate of ServiceDollar AmountType of Service Inpatient Outpatient/Doctor Visit Emergency Room Do you have another account to add? Yes No Account NumberDate of ServiceDollar AmountType of Service Inpatient Outpatient/Doctor Visit Emergency Room Do you have another account to add? Yes No Account NumberDate of ServiceDollar AmountType of Service Inpatient Outpatient/Doctor Visit Emergency Room Do you have another account to add? Yes No Account NumberDate of ServiceDollar AmountType of Service* Inpatient Outpatient/Doctor Visit Emergency Room Do you have another account to add? Yes No Account NumberDate of ServiceDollar AmountType of Service Inpatient Outpatient/Doctor Visit Emergency Room Uploading Documents This section is for attaching the documents we need to fully process your application and verify the information you provided.Proof of IncomePlease provide proof of income for any of the following that apply: A copy of your W2, payroll stubs from 3 months prior to the date of service with year-to-date gross income, Social Security/Disability income, pension income, Unemployment, VA benefits, Worker Compensation and any other sources of income. The following file types are permitted when uploading supporting documents. Images: .jpg, .jpeg, .png, .gif, .ico Documents: .pdf (Portable Document Format; Adobe Acrobat), .doc, .docx (Microsoft Word Document), .odt (OpenDocument Text Document), .xls, .xlsx (Microsoft Excel Document), .psd (Adobe Photoshop Document) Drop files here or Select files Max. file size: 50 MB, Max. files: 10. Medical Insurance and/or Medicaid Card – Front & BackPlease 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 Select files Max. file size: 50 MB, Max. files: 10. This field is hidden when viewing the formNumberThis field is hidden when viewing the formFamily AdditionalsThis field is hidden when viewing the formTotal Family SizeThis field is hidden when viewing the formFamily Additional Total 5380This field is hidden when viewing the formYearly Rate 15060This field is hidden when viewing the formTotal 3 Month Income Div by 3This field is hidden when viewing the formCalculated % FPL 3 MonthsThis field is hidden when viewing the formTotal 12 Month Income Div by 12This field is hidden when viewing the formCalculated % FPL 12 MonthsSignature*By my signature below, I certify that everything I have stated on this application and on my attachments is true. If incorrect information is provided at the time of application, this determination may be rescinded upon review. Are You Ready to Submit Your Application?* No 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.EmailThis field is for validation purposes and should be left unchanged.
