English Charity Care Application - Kaleida Health

Charity Care Program
Financial Counseling Services
726 Exchange Street, 2 nd Floor
Buffalo, NY 14210
Office: 716-859-8979 Fax: 716-859-8674
716-859-8657
APPLICATION FOR CHARITY CARE DISCOUNT
Household Information:
List names & dates of birth for every person living in the house
Last Name First Name D.O.B
Address:
Home Phone:
ASSETS:
List all bank accounts (exclude retirement accts)
Attach copies of current statement (s)
Bank Accts:
Checking Acct#: _______________________
Bank Name: __________________________
Balance: ___________________________
Savings Acct#: _______________________
Bank Name: __________________________
Balance: ____________________________
Cell phone:
HOUSEHOLD MONTHLY INCOME:
Wages:
________________
Social Security: ________________
Disability:
________________
Unemployment: ________________
Child Support: ________________
Pension:
________________
Alimony:
________________
Dividends, Interest: ________________
Rental Income: ________________
Other Income: ________________
Did you apply for Medicaid, Family Health Plus, or Child Health Plus? Yes No
If yes, Please provide proof of eligibility or denial.

Charity Care Program
Financial Counseling Services
726 Exchange Street, 2 nd Floor
Buffalo, NY 14210
Office: 716-859-8979 Fax: 716-859-8674
716-859-8657
I certify that the information provided in this application is true and accurate to the best of my
knowledge. Further, I will make application for any assistance (Medicaid, Medicare, Insurance,
etc.) which maybe available for payment of my hospital charges, and will take any action
reasonably necessary to obtain such assistance and will assign or pay to the hospital the amount
recovered for hospital charges.
I understand that this application is made so that the hospital can judge my eligibility under the
Kaleida Health Charity Care Policy. If any information I have given is untrue, I understand that the
hospital may re-evaluate my financial status and take whatever action deemed appropriate.
I agree to provide additional information as requested in order to determine eligibility. I agree to
inform Kaleida Health of any changes in my needs, insurance eligibility, income, living
arrangements and address as they occur.
I understand that I have 120 days from the date of service to submit a charity care application.
Signed: _________________________________________ Date: _____________________
Signed: _________________________________________ Date: _____________________
Pt Representative: ________________________________ Relationship: _______________
Date: ______________

Financial Assistance Application Process
To qualify for charity care, you must complete the application and provide necessary
documentation. You may be contacted by a facilitated enroller for financial screening
and to enroll in a government funded program if eligible. We will be happy to assist you
in completing and filing the application. Consideration will be given to complete
applications only.
Note: If your application for Medicaid, Family Health Plus, or Child Health Plus is
denied because you did not submit all of the information they require, your
request for charity care will also be denied.
Submit a completed application and the following items within 30 days of receipt of the
Charity Care application. Failure to provide this information will result in the denial of
your application.
A. Last 4 weeks pay check stubs, unemployment checks or other verifiable
proof of income from any other source including disability, pension, etc. for all
family members living in the household. For those self employed, please
include a three (3) month ledger.
B. Copies of current statements for all bank accounts, CDs, stocks, mutual
funds, or any other financial account(s). Retirement & education accounts
will not be considered
C. Copy of your Medicaid, Family Health Plus, and Child Health Plus approval or
denial letter. Letter must be dated within the past 6 months.
After all items are received, your request will be reviewed. You will be notified in writing
within 30 days of our determination. Please disregard any bills until you have received
the decision.
Approval will be valid for all services to include inpatient, emergency room, outpatient
and nursing home services rendered for one year from the date of approval In addition,
charity care discounts may be awarded on unpaid medically necessary services up to
120 days prior to the date of service. Requests for discount beyond 120 days will be
reviewed on case-by-case basis.
Please be advised that accounts over the 120 day time frame may be eligible for charity
care. However bad debt status may not be eligible for Charity Care and you will still be
responsible for payment.
IMPORTANT - The Charity Care program discounts do not cover prescriptions,
dental services unless performed in operating room environment (documentation
to support medical necessity may be requested) private physician charges,
elective non-medically necessary procedures, Medicaid client shares and spend
down, private room differentials, guest trays, telephone/television charges, no fault
and workers comp cases. Documentation to support medical necessity may be
requested.
Please return information to
Kaleida Health
Charity Care Program
Financial Counseling Services
726 Exchange Street, 3rd Floor
Buffalo, New York 14210
716-859-8979