The Health Council’s hospital members in Ohio have agreed to accept a common application form for patients seeking financial assistance. The purpose of the form is to reduce the paperwork burden for patient’s seeking financial assistance.
The application, which is provided in English and Spanish, does not replace a hospital’s current financial assistance form, but hospitals have agreed to accept the common form if presented by the patient.
The committee reviews the form annually to ensure it meets Ohio Hospital Care Assurance Program (HCAP) requirements and the needs of hospitals and their patients.
Read the Ohio Hospital Care Assurance Program Fact Sheet (Ohio Department of Job and Family Services)
Financial Assistance Form – English
Financial Assistance Form – Spanish