Financial Assistance Application FormDownload

Print your full name, your address at the time you received medical service and other information noted in this section

Phone Number Information

Health Insurance Information


Family Income

Provide income for yourself, your spouse and all other family members (if applicable).

Income Source Total for 3 Months Prior to Service Total for 12 Months Prior to Service
Wages/Self Employment
$
$
Social Security
$
$
Pension, Dividends, Interest, Rental Income
$
$
Unemployment, Workers’ Compensation
$
$
Child Support (only if the patient is the intended recipient)
$
$
Other
$
$

Family Information and Income

List all family members in your household and their date of birth.

Please provide the following information for all of the people in your immediate family who live in your home. Family is defined as the patient, the patient’s spouse, and all of the patient’s children under 18 (natural or adoptive) who live in the patient’s home. If the patient is under the age of 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.


Print your full name, your address at the time you received medical service and other information noted in this section

What telephone # and time of day best to contact:

1. Does the patient have insurance?

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2. Has the FAP applications been secured?

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MEDICAID FOR WOMEN, CHILDREN AND FAMILY PROGRAMS – If yes to any question, refer immediately.

1. Is the patient under the age of 18?

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2. Is the patient between ages 18 and under 21?

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3. Is the patient pregnant?

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4. Does the patient have any biological or adoptive children in household under 18 years of age?

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MEDICAID FOR THE AGED, BLIND, & DISABLED – If yes to any question, refer immediately.

1. Is the patient currently receiving SSI or SSD?

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2. Does the patient have any of the following conditions:

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  • Total Deafness
  • Total Blindness
  • Confinement to bed or wheelchair due to condition.
  • A stroke occurring three months ago, resulting in inability to walk independently.
  • Amputation of leg at hip
  • Cerebral Palsy, Muscular Dystrophy, or Muscular Atrophy, Down Syndrome
  • Requires hospice care for cancer
  • Severe prematurity
  • Spinal Injury resulting in the inability to walk

3. Is the patient 65 or older and not on Medicare?

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4. Have you been deemed Disabled by a Physician for at least a year?

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FOR CLEVELAND CLINIC INDIAN RIVER HOSPITAL USE ONLY:

If you are the patient, please DO NOT use this section.

I certify that everything I have stated on this application and on any attachments is true. By my signing below,

Patient Signature