Request Form - Winthrop University Hospital

NOTICE
Enclosed you will find an application for the Financial Assistance program. You have 110
days from the date of your hospital service or discharge to submit a completed Financial Assistance
application with all required documents attached (see below). However, Winthrop University Hospital
reserves the right to extend the 110-day requirement. This form must be completed and signed by the
patient or his/her guarantor and returned to Winthrop University Hospital at the following address:
Winthrop University Hospital
700 Hicksville Road, Suite 203
Bethpage, NY 11714
Att: Financial Assistance Determination
In addition to this form please provide photocopies of the following documents:
• Your IRS Forms W-2 and/or 1099 for the past year
• Current Pay stubs, Social Security statements, Unemployment or Compensation papers for
the past month
• Your income tax return for the past year _______________
• Other _________________________________________________________
_________________________________________________________
You will continue to be billed by the Hospital until supporting documentation has been
received and a final determination has been made. You are not required to make any payments to the
hospital until a final decision regarding your eligibility has been made, within 30 days after
submission of your completed application and required documentation.
If you have already submitted some proof that may qualify you for assistance you may see a
reduction to your bill while we await your submission of the completed Financial Assistance
application and other required documents. This reduction represents the minimum amount of relief
you will receive if all documents are received and your application is approved. Additional reductions
to your bill may be available, if your application is approved.
Please note that if you do not submit the application and documents within the required
time frame, or we determine that you are not eligible for Financial Assistance under our
guidelines, you will be re-billed and will be responsible to pay full charges for the services
provided to you.
If you have any question regarding our Financial Assistance policy or the completion of the
Financial Assistance Application, please call (516) 576-5600, option #3 and ask for assistance.

Account #______________________
REQUEST FOR DETERMINATION OF ELIGIBILITY FOR FINANCIAL ASSISTANCE
Patient’s Name_________________________________________________________________________________
First Middle Last Social Security #
Address_______________________________________________________________________________________
Number and Street City State Zip
Telephone No. (_____)_____________________Occupation_______________Employer______________________
Employer Address________________________________________ Employer Telephone # ___________________
INCOME - List combined income for yourself, spouse and other dependents from:
Total-last Month Total-Last 12 Months
WAGES…………………………………………….. $________________ $_______________
SELF EMPLOYMENT EARNINGS……………….. . $________________ $_______________
PUBLIC ASSISTANCE……………………………. $________________ $_______________
SOCIAL SECURITY………………………………. $________________ $_______________
UNEMPLOYMENT/WORKER’S COMP……….… $________________ $_______________
STRIKE BENEFITS…………..………………….… $________________ $_______________
ALIMONY……………………..…………………… $________________ $_______________
CHILD SUPPORT…………………………………. $________________ $_______________
MILITARY FAMILY ALLOTMENTS….………… $________________ $_______________
PENSIONS…………………….…………………… $________________ $_______________
INCOME FROM DIVIDENDS, INTEREST, RENT $________________ $_______________
RESOURCES………………………………………. $________________ $_______________
TOTAL………………… $________________ $_______________
As a condition to providing Financial Assistance, we are requesting proof of income / resources: 1) income tax return and /
or Form W-2 for the past year: 2) Current pay stubs, Social Security income, Pension Income, Unemployment or
Compensation papers for the past month, 3) other proof as requested. Proof means copies.
FAMILY SIZE - Family members living in your household
NAME AGE RELATIONSHIP
________________________________________ ___________________ ______________________
________________________________________ ___________________ ______________________
________________________________________ ___________________ ______________________
________________________________________ ___________________ ______________________
NOTE: PLEASE ATTACH ANOTHER SHEET, IF ADDITIONAL SPACE IS NEEDED.
I HEREBY REQUEST THAT WINTHROP UNIVERSITY HOSPITAL MAKE A WRITTEN
DETERMINATION OF MY ELIGIBILITY FOR FINANICAL ASSISTANCE. I UNDERSTAND THAT THE
INFORMATION WHICH I SUBMIT CONCERNING MY ANNUAL INCOME AND FAMILY SIZE IS
SUBJECT TO VERIFICATION BY THE HOSPITAL. I ALSO UNDERSTAND THAT IF THE INFORMATION
WHICH I SUBMIT IS DETERMINED TO BE FALSE, SUCH DETERMINATION WILL RESULT IN A
DENIAL OF PROVIDING SERVICES AS FINANCIAL ASSISTANCE, AND THAT I WILL BE LIABLE FOR
CHARGES FOR SERVICES PROVIDED.
I AFFIRM THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE. FURTHER, I HEREBY GIVE MY PERMISSION TO WINTHROP UNIVERSITY HOSPITAL
TO VERIFY ANY INFORMATION CONTAINED ABOVE.
DATE:________________________
SIGNATURE OF APPLICANT______________________________________