Online Application "*" indicates required fields Welcome to your Southern Ohio Medical Center online financial assistance application! To process your application, you will need to fill in the information that is requested. After reviewing your submitted application, we may reach out for additional documentation to support your income reported on the application. Household Members Information “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. Including yourself, what is the total number of people in your family?*Please enter a number from 1 to 10.Responsible Party/ApplicantName* First Last Date of Birth*Relationship to Patient*Additional Household Member 1Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 2Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 3Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 4Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 5Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 6Name* First Last Date of Birth*Relationship to Patient* Contact InformationResponsible Party/Applicant Name, if not patient First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number* Financial InformationWhat is the total family gross income (before taxes) for the previous 3 months? If none, enter 0.*What is the total family gross income (before taxes) for the previous 12 months? If none, enter 0.*If you report $0 income, please provide an explanation for how you are surviving financially. This explanation will be reviewed by a Financial Counselor and if further information is needed, we will contact you.* Insurance InformationDid the patient have Medical Insurance or Medicaid at the time of service?* Yes No Was the patient a resident of Ohio at the time of service?* Yes No Account Information Please provide the following information for all accounts you are responsible for that should be considered on this application. Guarantor NumberThe guarantor number can be found on your billing statement.Patient NamePatient's Date of BirthPlease list date(s) of service for this patient (MM/DD/YYYY)You are welcome to list multiple dates of service under each patient by placing a comma between each date. For example: 01/01/2023, 02/10/2023, 02/28/2023)Do you have another patient to add? Yes No Patient NamePatient's Date of BirthPlease list date(s) of service for this patient (MM/DD/YYYY)You are welcome to list multiple dates of service under each patient by placing a comma between each date. For example: 01/01/2023, 02/10/2023, 02/28/2023)Do you have another patient to add? Yes No Patient NamePatient's Date of BirthPlease list date(s) of service for this patient (MM/DD/YYYY)You are welcome to list multiple dates of service under each patient by placing a comma between each date. For example: 01/01/2023, 02/10/2023, 02/28/2023)Do you have another patient to add? Yes No Patient NamePatient's Date of BirthPlease list date(s) of service for this patient (MM/DD/YYYY)You are welcome to list multiple dates of service under each patient by placing a comma between each date. For example: 01/01/2023, 02/10/2023, 02/28/2023)Do you have another patient to add? Yes No Patient NamePatient's Date of BirthPlease list date(s) of service for this patient (MM/DD/YYYY)You are welcome to list multiple dates of service under each patient by placing a comma between each date. For example: 01/01/2023, 02/10/2023, 02/28/2023)Do you have another patient to add? Yes No Patient NamePatient's Date of BirthPlease list date(s) of service for this patient (MM/DD/YYYY)You are welcome to list multiple dates of service under each patient by placing a comma between each date. For example: 01/01/2023, 02/10/2023, 02/28/2023)Do you have another patient to add? Yes No Patient NamePatient's Date of BirthPlease list date(s) of service for this patient (MM/DD/YYYY)You are welcome to list multiple dates of service under each patient by placing a comma between each date. For example: 01/01/2023, 02/10/2023, 02/28/2023)Do you have another patient to add? Yes No Patient NamePatient's Date of BirthPlease list date(s) of service for this patient (MM/DD/YYYY)You are welcome to list multiple dates of service under each patient by placing a comma between each date. For example: 01/01/2023, 02/10/2023, 02/28/2023)Is there another guarantor number you would like to include? Yes No Guarantor NumberThe guarantor number can be found on your billing statement.Patient NamePatient's Date of BirthPlease list date(s) of service for this patient (MM/DD/YYYY)You are welcome to list multiple dates of service under each patient by placing a comma between each date. For example: 01/01/2023, 02/10/2023, 02/28/2023)Do you have another patient to add? Yes No Patient NamePatient's Date of BirthPlease list date(s) of service for this patient (MM/DD/YYYY)You are welcome to list multiple dates of service under each patient by placing a comma between each date. For example: 01/01/2023, 02/10/2023, 02/28/2023)Do you have another patient to add? Yes No Patient NamePatient's Date of BirthPlease list date(s) of service for this patient (MM/DD/YYYY)You are welcome to list multiple dates of service under each patient by placing a comma between each date. For example: 01/01/2023, 02/10/2023, 02/28/2023)Do you have another patient to add? Yes No Patient NamePatient's Date of BirthPlease list date(s) of service for this patient (MM/DD/YYYY)You are welcome to list multiple dates of service under each patient by placing a comma between each date. For example: 01/01/2023, 02/10/2023, 02/28/2023)Do you have another patient to add? Yes No Patient NamePatient's Date of BirthPlease list date(s) of service for this patient (MM/DD/YYYY)You are welcome to list multiple dates of service under each patient by placing a comma between each date. For example: 01/01/2023, 02/10/2023, 02/28/2023)Do you have another patient to add? Yes No Patient NamePatient's Date of BirthPlease list date(s) of service for this patient (MM/DD/YYYY)You are welcome to list multiple dates of service under each patient by placing a comma between each date. For example: 01/01/2023, 02/10/2023, 02/28/2023) This field is hidden when viewing the formNumberThis 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 5500This field is hidden when viewing the formYearly Rate 15650This field is hidden when viewing the formTotal 3 Month Income Div by 3This field is hidden when viewing the formCalculated % FPL 3 MonthsThis field is hidden when viewing the formTotal 12 Month Income Div by 12This field is hidden when viewing the formCalculated % FPL 12 MonthsSignature*By my signature below, I certify that everything I have stated on this application and on my attachments is true. 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.CommentsThis field is for validation purposes and should be left unchanged.
