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**CHAPPL*

*CHAPPL

Patient Financial Services Financial Assistance Application

Demographics

Medical Record/Guarantor # Is this visit related to Motor vehicle accident

Injury on your Job Neither

*Date of service (if not yet scheduled type “Future”)

*Last name *First name M.I. Social security number *Date of birth Address Apt. # City State ZIP code

How long have you lived at this address? *Are you homeless?

No Yes

Phone number

*Marital Status

Single Married Unmarried partner

*Dependents

No Yes

*Pregnant

No Yes

Please add your family member names including your significant other as well as anyone in your household who relies on you for care or anyone you claim as a dependent on your federal income tax return, if you file one. Family member name Date of birth Relationship Family member name Date of birth Relationship 1. 4.

2. 5.

3. 6.

Employment and other income

Please share the amounts and sources of family income below. Include wages/salary/income from any source for patient and spouse, and parents if patient is a minor.

*Employment status Employed Self-employed Not employed If employed, employer name Employer phone number

Current job 1 wages (before taxes): $ Weekly Every 2 weeks Monthly Annually Current job 2 wages (before taxes) $ Weekly Every 2 weeks Monthly Annually In the past year, did you: Change jobs Stop working Start working fewer hours None of these If so, when:

If self-employed, how much net income (profits once business expenses are paid) do you receive?

$ _ Monthly Annually

If not employed provide previous sources and amounts of family income: Source Amount $

Other sources of income:

Social Security / SSI Disability

$ Weekly Every 2 weeks Monthly Annually Alimony / Child Support Received

$ Weekly Every 2 weeks Monthly Annually Unemployment benefits

$ Weekly Every 2 weeks Monthly Annually Government benefits (SNAP, TANF, etc.)

$ Weekly Every 2 weeks Monthly Annually Assets

What is the total balance in your checking accounts, saving accounts, certificates of deposit and/or securities accounts?

$

*Do you have any individual retirement accounts (IRA, 401(k), 403(b), Keogh)? No Yes: the current value is: $

*Do you own an automobile(s)? No Yes If yes, provide detail below. Year Make Model Value Monthly payment Balance due

1. $ $ $

2. $ $ $

3. $ $ $

*Do you receive income from interest, dividends or investments? No Yes: the total amount is: $

*Do you: Rent your home: Monthly payment/rent $

Own your home: Current value $

Do not rent or own: Where or with whom do you live? I certify that the information provided is true and correct to the best of my knowledge and belief. I understand that Inova will require proof of income and residency, and I authorize Inova to request from and release to any affiliated entities and/or third parties any information needed to complete the application process. I will apply for and take any action reasonably necessary to obtain assistance for payment and will assign or pay the amount recovered to Inova. If any information I have given proves to be untrue, I understand that the hospital may re-evaluate my financial status and take whatever action becomes appropriate. Applicant (signature): Applicant (print name): Date: Time:

*Items with asterisks are required. CAT # 31474/R061324 l PKGS OF 100

Federal Poverty Guidelines, 2024

Appendix A

Federal Poverty Guidelines, 2024

Family Size 100% 250% 400% 500%

1 $15,060 $37,650 $60,240 $75,300

2 $20,440 $51,100 $81,760 $102,200

3 $25,820 $64,550 $103,280 $129,100

4 $31,200 $78,000 $124,800 $156,000

5 $36,580 $91,450 $146,320 $182,900

6 $41,960 $104,900 $167,840 $209,800

7 $47,340 $118,350 $189,360 $236,700

8 $52,720 $131,800 $210,880 $263,600

9 $58,100 $145,250 $232,400 $290,500

10 $63,480 $158,700 $253,920 $317,400

For families/households with more than 10 persons, add $5,380 for each additional person. Appendix C 5/2024

Appendix C

Financial Assistance Required Documentation Checklist In addition to completing the Inova Financial Assistance application, you will need to provide proof of your income and residency from the list of options below that will satisfy Inova’s Financial Assistance Policy requirements. Please note that your application submission must be within 240 days from first statement date to be eligible for review and circum decision.

IMPORTANT: Failure to submit the required signed and dated application and required documentation for proof of individual/family income and residency will result in the DENIAL of your application. If you are denied for financial assistance, the outstanding balance will remain as patient responsibility, and you will receive Inova patient billing statements for the amount due. Please allow 30 days for our team to review and determine your eligibility for Financial Assistance. Additional documentation may be requested and submitted during this time. A decision letter will be sent to you via certified mail and/or will be visible in MyChart within that 30-day term defined within Inova’s Financial Assistance Policy Requirements. For questions, please call the Inova Financial Assistance Team: 571-***-****. Individual/Family Income Requirement

If a spouse or partner lives with you, their income documentation is also required. Must include one (1) of the following from the list below: Residency Requirement

Proof of 30-days of Virginia residency prior to any services received at Inova is required.

Must include one (1) of the following from the list below: Most recent federal income tax return:

Please submit the full tax return documentation with date and signature.

Between January and April this will not be accepted. The two most recent paystubs should be submitted instead.

Valid Virginia-issued Driver License or Identification Card, Virginia Voter Registration Card, Virginia DMV records:

Document must have been issued at least 30 days prior to the date of service.

Two Most Recent Paystubs:

Paystubs must show gross income before deductions, pay period date and year to date earnings.

Most recent federal income tax return:

Please submit the full tax return documentation with date and signature.

Verification of Employment:

If tax return or paystubs are unavailable, employer may complete this form/letter.

Download from www.Inova.org/patients-visitors/financial-assistance Utility bill or bank statement:

Document must reflect applicant’s name and current address.

Document must have been dated/generated at least 30 days prior to the Inova date of service.

Verification of Residency:

Form is to be completed by landlord/property owner.

Download from: www.inova.org/patients-visitors/financial- assistance

Verification of Support:

Form is intended for patients who are unemployed and receiving support from family/friend/other.

Form is to be completed by the person (family/friend/other) helping to support with shelter, food and/or living expenses. This document does not assign the person completing the form any financial responsibility of outstanding medical debt due from the patient who is applying for financial assistance.

Taxes will be requested of supporters in the same household to determine if patient is claimed as a dependent.

If recently unemployed, please also provide documentation from the previous place of employment.

Download from: www.Inova.org/patients-visitors/financial-assistance School records:

Documents must reflect child name, school name and current address.

School must be accredited by a US state, jurisdiction or territory.

This may include a transcript, Emergency Care Form, letter or other documentation that can be requested from the school or downloaded from a virtual portal.

Verification of Self-Declaration:

Intended for patients who are day workers, migrant/seasonal workers, earn tips as their income or who are unemployed and not receiving support from family/friend/other with shelter, food and/or living expenses.

If recently unemployed, please also provide documentation from previous place of employment.

Download from: www.Inova.org/patients-visitors/financial-assistance Other Income-Related Documentation that may be requested include (but are not limited to)*:

Social Security benefit letter, pension, retirement income, survivor benefits, unemployment benefits, government assistance program, public assistance benefit letter, interest dividends, royalties, income from estate/trust, education/tuition assistance documentation, alimony/child support documentation, ambassador status verification on embassy letterhead, third-party income verification (home lease, purchase application, automobile lease, loan application, etc.), I20 Form (international students), child’s birth certificate, letter of circumstances

*Please call the team for more information: 571-***-****. Other Residency-Related Documentation that may

be requested include (but are not limited to)*:

Lease agreement, receipt for personal property tax in Virginia or real estate taxes paid within the last year to the Commonwealth of Virginia or a Virginia locality, Virginia Department of Education Certificate of Enrollment, immigration residency certification document, W2

*Please call the team for more information: 571-***-****. Appendix C 5/2024

How to submit your completed/signed financial assistance application including proof of income and residency

MyChart

Upload completed and signed application and all required residency and income documentation to MyChart: Log in or create an account within MyChart: https://mychart.inova.org/mychart 1. Once logged in, navigate to the menu in the top left-hand corner of the home screen. 2. Scroll down to the “Billing” Category and select “Financial Assistance.” 3. Complete each screen and upload a completed and signed Application, as well as your income and residency documents that are required in the designated order as prompted. 4. Once all documents have been uploaded and appropriate fields have been filled in within each screen, click Submit.

The processing team will then begin the review of your case and communicate status of your submission and approval or denial decision, or a request for additional documentation if needed. Mail

Mail the completed and signed application and all required residency and income documentation to: Inova Patient Financial Services

Attn: Rev Cycle Financial Assistance Department

8095 Innovation Park Drive

Fairfax VA 22031

This location does not accept patient walk-ins.

Fax

Fax the completed and signed application and all required residency and income documentation to: Fax #: 571-***-****

Attn: Rev Cycle Financial Assistance Department

Drop Off

Drop off your completed and signed application and all required residency and income documentation to: Inova Partnership for Healthier Communities

2700 Prosperity Ave., #280

Fairfax VA 22031

Monday to Friday 8:30am – 5:00pm

(In person assistance available Monday to Friday 8:30am – 12:00pm.)

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