Online Application "*" indicates required fields Welcome to your Blanchard Valley Health System online financial assistance application! In order to process your application, income verification documents must be submitted with the application. These can include pay stubs, W-2, social security award letter, etc. These must be provided for the 3-month period prior to your date of service. Bank statements do not qualify as verification of income.**Income is based off gross amounts**After reviewing your submitted application, we may reach out to assist you with additional programs and insurance options available to you. Please get an electronic copy or pictures of your documents ready before starting your application. If you submit an incomplete application, we will reach out to you via mail for any additional information or documentation needed to process your application. Patient Name* First Last Patient Date of Birth*Social Security NumberEncounter NumberDate(s) of Service*What was the patient's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was the patient's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Is the Patient also the Responsible Party/Applicant? Yes No If no, who is the Responsible Party/Applicant?* First Last Relationship to the patientDate of Birth*What was the applicant's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was the applicant's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Address* Street Address City State Zip Code Phone Number*Were you an Ohio resident at the time of your hospital service?* Yes No Including yourself, what is the total number of people living in your household?*“Family” is defined as the responsible party, the responsible party’s spouse (if applicable), and all of their natural or adoptive children under 18 who live in their home.Please enter a number from 1 to 9.Additional Household Member 1 – Name* First Last Additional Household Member 1 – Name* First Last Additional Household Member 1 – Date of Birth*Additional Household Member 1 – Date of Birth*Additional Household Member 1 – Relationship to Patient*Additional Household Member 1 – Relationship to Patient*What was Additional Family Member 1's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 1's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 1's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*What was Additional Family Member 1's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Household Member 2 – Name* First Last Additional Household Member 2 – Name* First Last Additional Household Member 2 – Date of Birth*Additional Household Member 2 – Date of Birth*Additional Household Member 2 – Relationship to Patient*Additional Household Member 2 – Relationship to Patient*What was Additional Family Member 2's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 2's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 2's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*What was Additional Family Member 2's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Household Member 3 – Name* First Last Additional Household Member 3 – Name* First Last Additional Household Member 3 – Date of Birth*Additional Household Member 3 – Date of Birth*Additional Household Member 3 – Relationship to Patient*Additional Household Member 3 – Relationship to Patient*What was Additional Family Member 3's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 3's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 3's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*What was Additional Family Member 3's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Household Member 4 – Name* First Last Additional Household Member 4 – Name* First Last Additional Household Member 4 – Date of Birth*Additional Household Member 4 – Date of Birth*Additional Household Member 4 – Relationship to Patient*Additional Household Member 4 – Relationship to Patient*What was Additional Family Member 4's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 4's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 4's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*What was Additional Family Member 4's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Household Member 5 – Name* First Last Additional Household Member 5 – Name* First Last Additional Household Member 5 – Date of Birth*Additional Household Member 5 – Date of Birth*Additional Household Member 5 – Relationship to Patient*Additional Household Member 5 – Relationship to Patient*What was Additional Family Member 5's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 5's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 5's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*What was Additional Family Member 5's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Household Member 6 – Name* First Last Additional Household Member 6 – Name* First Last Additional Household Member 6 – Date of Birth*Additional Household Member 6 – Date of Birth*Additional Household Member 6 – Relationship to Patient*Additional Household Member 6 – Relationship to Patient*What was Additional Family Member 6's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 6's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 6's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*What was Additional Family Member 6's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Household Member 7 – Name* First Last Additional Household Member 7 – Name* First Last Additional Household Member 7 – Date of Birth*Additional Household Member 7 – Date of Birth*Additional Household Member 7 – Relationship to Patient*Additional Household Member 7 – Relationship to Patient*What was Additional Family Member 7's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 7's total gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 7's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*What was Additional Family Member 7's total gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*If there is no income, please explain how patient is supporting self: Patient's Employer Name (If Applicable)Date HiredDate EndedPatient's 2nd Employer Name (If Applicable)Date HiredDate EndedApplicant's Employer Name (If Applicable)Date HiredDate EndedApplicant's 2nd Employer Name (If Applicable)Date HiredDate EndedSpouse/Other Employer Name (If Applicable)Date HiredDate EndedSpouse/Other 2nd Employer Name (If Applicable)Date HiredDate Ended Were you an active Medicaid recipient at the time of your service?* Yes No If yes, please enter your Medicaid Billing Number.Did you have health insurance (other than Medicaid) at the time of your hospital service?* Yes No Insurance Company NameInsurance Company Phone NumberInsurance Group NumberInsurance Member IDWas this service related to any of the following?* Auto Accident Work Injury Third-Party Liability Claim None of the above Is there any attorney representation or settlement expected? Yes No Uploading Documents This section is for attaching the documents we need to fully process your application and verify the information you provided. Please include copies of all of the following that apply to your household. Pay StubsPlease upload paystubs for all income earners, for 3-months prior to date of service, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. W-2'sPlease upload W-2’s for all income earners, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Other Income StatementsPlease upload any other statements received from income sources (Social Security, alimony/child support, unemployment, retirement/pension, etc.), for 3-months prior to date of service, if applicable. Drop files here or Select files Accepted file types: jpjpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Medical Insurance and/or Medicaid Card – Front & BackPlease attach pictures or copies of the front and back of your medical insurance or Medicaid card effective at the time of service, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. This field is hidden when viewing the formTotal Family Income 3 months prior to the date of service?This field is hidden when viewing the formTotal Family Income 12 months prior to the date of service?This field is hidden when viewing the formFamily AdditionalsThis field is hidden when viewing the formTotal Family SizeThis field is hidden when viewing the formFamily Additional Total 5380This field is hidden when viewing the formYearly Rate 15060This field is hidden when viewing the formAnnual Income based on 3mos priorThis field is hidden when viewing the formCalculated % FPL 3 MonthsThis field is hidden when viewing the formCalculated % FPL 12 MonthsPatient/Guarantor Signature*By my signature below, I certify that everything I have stated on this application and any attachments is true. I give Blanchard Valley Health System permission to evaluate my financial status and determine eligibility for various financial assistance programs. In addition, I realize that any money received to me by an insurance company or third-party liability award, due to services performed for the specific dates of service covered by this application could result in my financial assistance being reversed. I accept responsibility for full and immediate payment of any and all outstanding balances. Are You Ready to Submit Your Application?* No I’m Ready On a scale from 1-5, with 1 being HARD and 5 being EASY, how was your experience applying for Financial Assistance online?Please enter a number from 1 to 5.Great! Please do not close your browser or leave this page until you see the confirmation page.Unique IDPhoneThis field is for validation purposes and should be left unchanged.
