Financial Assistance Application Form - Nyu Physician Services, Nyu Langone Medical Center Faculty Group Practice Page 2

Download a blank fillable Financial Assistance Application Form - Nyu Physician Services, Nyu Langone Medical Center Faculty Group Practice in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Financial Assistance Application Form - Nyu Physician Services, Nyu Langone Medical Center Faculty Group Practice with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Complete Applications must include proof of income which can include:
1. Copies of pay stubs
2. Most recent W2 Forms and/or 1099s
3. Copy of application materials submitted to hospital patient financial services
4. Unemployment Documentation
5. Most Recent Tax Return
6. Copies of Medicaid, Family Health Plus or Child Health Plus application materials
7. Letter of support
8. Other Supporting Documents
CERTIFICATION
I certify that the above information is true and accurate to the best of my knowledge. I understand that fraudulent
I understand that incomplete
or misleading information will make me ineligible for any financial assistance.
applications are unable to be processed.
I authorize the release of any information needed to verify the information
provided and for billing and collections in compliance with applicable federal and state laws.
I understand that this application is made so that the Faculty Group Practice can determine my eligibility for
Financial Assistance based on the established criteria on file.
In addition, I agree to provide additional information as requested in order to determine eligibility. I agree to
inform the FGP of any change in my needs, insurance eligibility, income, property, and living arrangements or
address as they occur.
By signing below, I acknowledge that the information I provided is correct to the best of my ability.
Patient Signature: ______________________________________________________ Date: ______/______/______
Guarantor Signature (if other than patient):__________________________________ Date: ______/______/______
Please contact our customer service team at 1-877-648-2964 with questions about your application

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Financial Assistance Application Form Financial Assistance Application Form Business
Financial Assistance Application Form Financial Assistance Application Form Business
Financial Assistance Application Form - South Sound Ymca Financial Assistance Application Form - South Sound Ymca Business
Financial Assistance Application Form - Ymca Of Frederick County Financial Assistance Application Form - Ymca Of Frederick County Business
Financial Assistance Application Form Financial Assistance Application Form Business
Ymca Financial Assistance Application Form Ymca Financial Assistance Application Form Business
Grant/financial Assistance Application Form (spanish And English) Grant/financial Assistance Application Form (spanish And English) Business
Child Care Financial Assistance Application Form - Ymca Child Care Financial Assistance Application Form - Ymca Business
Financial Assistance Application Financial Assistance Application Financial
Financial Assistance Application Event/destination Form Financial Assistance Application Event/destination Form Business

Related Categories

Parent category: Business
Download
Go
Page of 2