Print your full name, your address at the time you received medical service and other information noted in this section
Date of Birth
Phone Number Information
Health Insurance Information
Family Income
Provide income for yourself, your spouse and all other family members, including children in the household. (if applicable).
The child must live on a continual basis in the home of the parent or with whom the child spends most nights. In cases where the child spends equal time with both parents and custody becomes an issue, the child must be included in the household of the parent who claims the child as a tax dependent.
Family Information
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.
SSN/DOB
What telephone # and time of day best to contact:
1. Does the patient have insurance?
2. Has the FAP applications been secured?
MEDICAID FOR WOMEN, CHILDREN AND FAMILY PROGRAMS – If yes to any question, refer immediately.
1. Is the patient under the age of 18?
2. Is the patient between ages 18 and under 21?
3. Is the patient pregnant?
4. Does the patient have any biological or adoptive children in household under 18 years of age?
MEDICAID FOR THE AGED, BLIND, & DISABLED – If yes to any question, refer immediately.
1. Is the patient currently receiving SSI or SSD?
2. Does the patient have any of the following conditions:
3. Is the patient 65 or older and not on Medicare?
4. Have you been deemed Disabled by a Physician for at least a year?
IF THE ANSWER IS YES TO ANY OF THE ABOVE QUESTIONS, REFER ACCOUNT TO FASU FOR MEDICAID ELIGIBILITY ASSISTANCE. MAKE SURE TO SEND THE COMPLETED, SIGNED APPLICATION FOR FINANCIAL ASSISTANCE WITH THIS REFERRAL.
FOR CLEVELAND CLINIC INDIAN RIVER HOSPITAL USE ONLY:
If you are the patient, please DO NOT use this section.
Cleveland Clinic Indian River Hospital has received authorization to complete this form on behalf of the patient.
I certify that everything I have stated on this application and on any attachments is true. By my signing below,
Patient Signature
