Albany Medical Center
ADVERTISEMENT
1
2
32014
ALBANY MEDICAL CENTER / SOUTH CLINICAL CAMPUS /COLLEGE
FINANCIAL AID PROGRAMS APPLICATION
Please complete the following application to the best of your ability so that we may determine your eligibility for
Albany Medical Center/SCC’s Financial Aid Programs including: Charity Care, Bellinger Fund, Caring Together
Fund, Pediatric Hearing Fund and other available discounting. Charity Care is available only to those households
with savings, investments, and other assets less than $10,000.00. You are entitled to exclude your primary home,
car, retirement and education savings. Albany Medical Center/SCC requires applicants to apply or be screened for
Medicaid benefits where appropriate. If you have any questions please call the Business Office at Albany Medical
Center/SCC.
Translation service and application assistance will be provided if requested. Please call 518-262-1981 to request
assistance.
Completed applications should be forwarded to:
Patient Financial Services
Albany Medical Center/SCC
99 Delaware Avenue
Delmar, NY 12054
Attn: Charity Care Specialist
Fax: 518-262-2003
Patient’s Information
Applicant’s Name:
____________________________________________________________________
(Please Print)
(Last Name)
(First Name)
(MI)
Social Security Number
__________________________ (Optional)
Address:
______________________________________________________________
City:
______________________
State: ________
Zip Code: ____________
County of Residence: __________________________
Home Phone:
________________________ Work Phone: ________________________
Date of Birth: _____/_____/_________
Sex: _______
Marital Status: ___________
__________
Number of members in household
*If you receive a billing statement before you are notified of decision, please contact our office at 518-262-1981.
PLEASE RETURN THE APPLICATION BY__________________________.
Revised 01/01/14
1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal