Financial Assistance Application

Assistance provided is for services rendered at Hospital for Special Surgery only.

1. Medical Record Number

2. If you have spoken to someone at HSS already in regards to Financial Assistance, please provide their name

3. Patient Information

Last Name *This question is required.

First Name *This question is required.

Middle Initial

Street Address *This question is required.

Apt/Suite

City *This question is required.

State *This question is required.

Zip *This question is required.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Email Address *This question is required. This question requires a valid email address.

Best Contact Number

Alternate Contact Number

4. Contact Person

Name

Relation to patient

Contact Number

5. Insurance Information

Insurance Plan *This question is required.

Policy Number

Insurance Phone Number

6. Clinical Service Requested

7. List all Persons living in home and legally dependent upon you for support:
(As claimed as dependents on your income tax return)

8. Are you seeking care that is not reasonably available closer to your residence?

9. Are you seeking highly specialized care that is not reasonably available at other hospitals?

10. Income Check the box if true:

11. Total gross monthly income from different income sources

Space Cell	Household income 3 months	Household income 12 months
Wages	Household income 3 months	Household income 12 months
Social Security Payment	Household income 3 months	Household income 12 months
Dividends, Interest, Rental Income	Household income 3 months	Household income 12 months
Unemployment Compensation	Household income 3 months	Household income 12 months

12. Current checking/savings account balances

13. Please upload the following information for household income verification:

Pay stubs from the most current available three (3) month period
Oral or written income verification from public assistance agencies
Flexible Spending Account or Health Care Savings Account election information and balance
Form approving or denying unemployment compensation
Bank account or investment statements
SSI Benefit Statement or Benefit Determination
Self-Attestation

Applicants need not provide each item if the information is not available.

14. Certification *This question is required.

I certify that the above information is complete and correct. I understand that the information, which I submit, is subject to verification by Hospital for Special Surgery and subject to review. Further, I will take all steps necessary to apply for any assistance (Medicaid, Medicare, Insurance, etc.) which may be available for payment of my applicable charge. I will take any action reasonably necessary to obtain such assistance and will assign or pay the applicable provider the amount recovered for applicable charges. I understand that if any of the information I have given proves to be incomplete or untrue, the hospital may re-evaluate my financial status and take whatever action it deems appropriate. If my ability to pay changes significantly subsequent to the date of this application, I will inform the hospital.

15. Signature

Type your Full Name *This question is required.

Relation to patient

Date This question requires a valid date format of MM/DD/YYYY.

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