If you have questions while filling out this application, please contact a Patient Account Specialist at 308.254.8778. Once your application has been received, a Patient Account Specialist will contact you regarding your qualification.
All answers should be for the entire household.
1) 65 years of age or older.
2) An individual under 65 years of age who has a disability or is visually imparted according to Social Security guidelines. If possibly disabled, patient should apply for disability and Medicaid prior to receiveing charity care. (Patients will provide case numbers for each application.)
3) An individual 19 years of age or younger.
4) A dependent child who meets the eligibility requirements of the Aid to Dependent Children Program.
Once you have completied the Charity Care application, please understand that a determination of Charity Care eligibility will not be made until the denial letter from Medicaid is received by one of our Patient Account Specialists.
Select one of the following ways to apply:
1) Phone at 855.632.7633
2) Online at http://http://dhhs.ne.gov/children_family_services/accessnebraska/Pages/accessnebraska_index.aspx
3) In person at your local Department of Health and Human Services.
Application should be submitted with the following supporting documentation include current year W-2’s, tax return, unemployment statement and may include a Medicaid denial letter, if applicable. If W-2’s are not applicable or taxes were not filed, submit the last three months of most current pay stubs.
By submitting this application, I certify that the information provided is as complete and true to the best of my ability. I also understand that if I make false statements on this application, any adjustment I receive from the SRMC Charity Care Program could be withheld and/or reversed at a future date. I authorize SRMC to use any information contained in the application to verify my eligibility for adjustment from SRMC Charity Care Program, and to obtain records pertaining to eligibility from a financial instituion as defined in Section 15-15-201(4), C.R.S. or from any insurance company.
I understand that SRMC has the right to obtain any recovery or right of recovery for a patient who would have has a right of recovery. This means that if I am found to have a claim for any benefits payable for any treatment, which is given while I am eligibly for the SRMC Charity Care Program, that SRMC has the right to be included in the claims process. I also understand that should I faile to keep any payment arrangements made with SRMC on the ramaining balance fo my account(s), any adjustment received may be reversed and my account(s) will be sent to any external collection agency.
For Charity Care - Information for Entire Household
LIST ALL PERSONAL, TRUST PARTNERSHIP, OR CORPORATE DEBTS. INCLUDE RENT, DEBTS FOR 1ST AND 2ND LIEN LOANS (MORTGAGE OR TRUST DEED), SRMC DEBT. AUTOS, APPLIANCES, FURNITURE, PERSONAL LOANS AND NOTES, CO-SIGNED NOTES, GARNISHMENTS/JUDGEMENTS, AND CREDIT CARD/CHARGE ACCOUNTS.
Please print this document before submitting in order to save for your records or provide to billing.