FA Application – Southern Ohio Medical Center Financial Assistance

Online Application

Welcome to your Southern Ohio Medical Center online financial assistance application!

In order to process your application, we will need supporting documents to verify your financial situation. Required documents include: paystubs or other proof of income for all household members, if applicable After reviewing your submitted application, we may reach out to assist you with additional program and insurance options available to you, or request additional documentation.

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 for any additional information or documentation needed to process your application.

Do you have your proof of income documents ready?*

Yes

I will mail in or drop off my proof of income documents to SOMC in the next 10 days.*

The address to send or drop off your documents to is: 1207 17th Street, Portsmouth, OH 45662.

Yes

Household Members Information

Please provide the following information for all people in your immediate family who live in your home. “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/Applicant

Name*

First Last

Date of Birth*

Relationship to Patient*

Additional Household Member 1

Name*

First Last

Date of Birth*

Relationship to Patient*

Additional Household Member 2

Name*

First Last

Date of Birth*

Relationship to Patient*

Additional Household Member 3

Name*

First Last

Date of Birth*

Relationship to Patient*

Additional Household Member 4

Name*

First Last

Date of Birth*

Relationship to Patient*

Additional Household Member 5

Name*

First Last

Date of Birth*

Relationship to Patient*

Additional Household Member 6

Name*

First Last

Date of Birth*

Relationship to Patient*

Contact Information

Patient Name*

First Last

Responsible Party/Applicant Name, if not patient

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Financial Information

Has anyone in your household received income in the last 12 months?*

Yes

What is the total family gross income (before taxes) for the previous 3 months?*

What is the total family gross income (before taxes) for the previous 12 months?*

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.*

Is your total checking and savings accounts balance greater than $10,000?*

Yes

Insurance Information

Did the patient have Medical Insurance or Medicaid at the time of service?*

Yes

Was the patient a resident of Ohio at the time of service?*

Yes

Account Information

Please provide the following information for all accounts you are responsible for that should be considered on this application.