1 Shircliff Way Jacksonville, FL 32204

PHONE: (904) 308-1956 FAX: (904) 308-5910

Patient’s Name: Date:

Please circle YES or NO to the following questions:

YES NO Do you have insurance? Name of Insurance Carrier: ___________________ Member ID number: ________________________

YES NO Are you over the age of 65?

YES NO Have you ever been in the military?

YES NO Do you have minor children in custody?

YES NO Are you under the age of 21?

YES NO Have you been deemed disabled by Social Security?

YES NO Do you have a disability case pending?

YES NO Are you pregnant?

YES NO Are you a U.S. Citizen?

Please indicate the reason(s) you are applying for HOPE:

(You may check more than one)

□ Outstanding hospital bills

□ I am a Diagnostic Cardiology patient

□ I was admitted as an inpatient to SVMC from the Emergency Room and I am in need of continuation of care.

□ I was referred by a physician: Physician’s Name:___________________□ I wish to renew my HOPE benefits

□ Other (please explain):

**APPLICATIONS CAN TAKE UP TO 45 DAYS TO PROCESS**

HOPE APPLICATION INSTRUCTIONS-PLEASE READ

□ Application Checklist for HOPE Please provide copies of all required documents. Applications are not accepted without all of the documents required. Applications received without all required documents will be returned.

□ Financial Assistance/HOPE Application Please complete all sections of this page: List all family members that live in the same house or are temporarily absent from the home. Family is defined as everyone that lives in the same house that is related to you by birth, marriage or adoption.

□ List All Family Members Please complete all sections of this page: List all family members that live in the same house or are temporarily absent from the home, even if they are already included on the previous page.

□ Financial Information Release (FL residents only) Please sign and date on the signature(s) line. If married, patient and spouse must sign

□ Designated Representative (GA residents only) Please sign and date

□ Appointment of Designated Representative (FL residents only) Please sign on the “Signature of Customer” line and date. Do not enter a name for the representative. This will be an R1 employee.

□ HIPPA Authorization Form Please sign and date

□ R1 Authorization for Patient Representation Please sign and date

□ Financial Assistance Agreement Please initial all lines, sign, and date

□ Authorization for Release of Protected Health Information Please sign and date

□ Affidavit of Support Please sign and date

□ Homeless Attestation Form Please sign and date

Application Checklist for HOPE

Patient:

Photo ID

Copy of Social Security Card Previous year Income Tax Return (not 1099 or W2)

OR Verification of Non Filing (visit www.irs.gov/form 4506-T for instructions)

Income Verification for Family: (Family is defined as everyone that

lives in the same house that is related by birth, marriage or adoption. Previous year Income Tax Return (not 1099 or W2) OR Verification

of Non Filing (visit www.irs.gov/form 4506t for instructions)

If employed; All pay stubs from the last 3 months (paid weekly=12 stubs, bi-weekly=6 stubs, etc.)

If unemployed and receiving no income (patient only); Affidavit or Letter or Support written and signed by someone other than yourself, with a copy of their photo ID.

If you receive or are receiving Unemployment Compensation; Letter of Benefits

If you receive Social Security; Letter of Benefits. This is the letter you received stating how much you receive each month, not the 1099 from the previous year.

Proof of any other income you are receiving (i.e. child support, pension, retirement, etc.) This would be a statement from the provider.

If you are Homeless; Homeless Attestation Form.

If you are Self Employed; a current year-to-date Profit & Loss statement, if you were self-employed in the previous year; previous year tax returns Schedule C.

**NOTE** Bank statements are not acceptable proof of income.

Financial Assistance/HOPE Application

Patient Name: D.O.B Account #:

Guarantor if not patient: Phone: Cell: Email:

Residence Address: City: State: Zip:

Mailing Address if not same: _________________________________ City: ____________________________State: _________ Zip: ___________

Have you applied for Medicaid? (Circle One) YES NO If yes, please provide a copy of your approval or denial letter.

List yourself and all other family members who live in the home or are temporarily absent from the home

Full Name

Relationship to you

Date of Birth Gross Yearly Income For Family

(anyone who lives in the same house that is

related by birth, marriage or adoption)

Source of Income: Choose the one that

applies W= Wages D = Disability WC = Workers Comp OT = Other U = Unemployed P= Pension UC=Unemployment Compensation CS = Child Support SS= Social Security

SELF-Self Employed

Self

Total in Family Total GROSS Annual Income:

If you have no regular verifiable income, please explain how you support yourself and/or your family:

Employment: List any family member that is employed or self-employed.

Name of Employed Person Employer’s Name (Phone #)

Hours per Week Wages per Hour How often paid

Your request for financial assistance for St. Vincent’s Medical Center may be denied if you fail to comply with any of the steps listed or if the information that you submit is determined to be false. We also reserve

the right to run a credit check on applicants requesting assistance. Please mail ALL verifications to the address listed in the summary for the facility in which you are applying with attention to: HOPE Office.

Signature: Date:

FIRST NAME

M.I.

LAST NAME

RELATIONSHIP

TO PATIENT

SEX

MARITAL STATUS

DOB

Social Security

Number

US

CITIZEN

Self

M F

Y N

M F

Y N

M F

Y N

M F

Y N

M F

Y N

M F

Y N

M F

Y N

M F

Y N

M F

Y N

MARITAL STATUS S = Single, Never Married M = Married D = Divorced X = Separated W = Widowed

LIST ALL FAMILY MEMBERS (List yourself and all other family members who live in the home or are

temporarily absent from the home even if they are listed on the previous page)

State of Florida Estado De La Florida

Department of Children and Families

Departamento de Ninos y Familias

FINANCIAL INFORMATION RELEASE

Autorizacion Para lnforme Economico

Date (Fecha): _

Case Number or ACCESS Number

(Numero def Caso o Numero de ACCESS)

To Whom It May Concern: (A Quien Pueda lnteresar):

I hereby grant permission and authorize any bank, building association, employer,

insurance company, real estate company, government agency or any financial institution of

any kind or character to disclose to any agent of the Department of Children and Families

full information as to my bank accounts, earnings, insurance policies, property or benefits,

for the time period listed below.

(Par la presente autorizo a cua/quier banco, compafiia de construcci6n, compafiia de

seguros, compafiia de bienes raices, agencia de gobierno o instituci6n financiera que a sf

lo solicite, a suministrar informaci6n sabre mis cuentas bancarias, ingresos, polizas de

seguro, propiedades o beneficios, par el periodo de tiempo abajo indicado, a cualquier empleado de/ Departamento de Ninos y Familias.)

This release is valid from to _

(Esta autorizaci6n es valida desde hasta .)

Signature(s): (Firma(s))

Name(s) on Account:

(Nombre(s) en la Cuenta)

ESS Specialist Signature Date

CF-ES 2613, PDF 10/2005 [65A-1.400, F.A.C.]

St. Vincent’s HealthCare

P.O. Box 45167

Jacksonville, FL 32232

Date:

Designated Representative

I, understand that by submitting my signature I am

(Patient Name)

authorizing the Georgia Division of Family and Children Services (DFCS) to release information to

St. Vincent's Health System and their representatives. This release is made to St. Vincent's

Health System and Care Coverage, a division of R1 and shall be used solely to fulfill their

obligation in assisting me with my Medicaid application. Information to be released is limited to:

Status of application (approved, denied, enrolled or pending)

Reason for closure or denial

Scheduled interview dates and time

Verifications requested and dates due

Patient Signature Financial Counselor’s Name and Phone #

Medical Record Number

Case Number

APPOINTMENT OF A DESIGNATED REPRESENTATIVE

Customer’s Name

Completed by Customer

I would like for to act on my behalf in determining my Name of Representative

eligibility for public assistance from the Department of Children and Families.

Signature of Customer Date

Completed by Representative

I understand that by accepting this appointment, I am responsible to provide or assist in providing information needed to establish this person’s eligibility for assistance. I understand that I may be prosecuted for perjury and/or fraud if I withhold information or intentionally provide false information.

Signature of Representative Date

Relationship to Customer Street Address

City State

Phone Number

Self-Appointment by Representative

I am acting for in providing information to establish eligibility for assistance because he/she is unable to act on his/her own behalf. I will provide information to the best of my knowledge. I understand that if I withhold information or if I intentionally provide false information, I may be prosecuted for perjury and/or fraud. I agree to immediately report any change in their situation of which I become aware.

Signature of Representative Date

Relationship to Customer Street Address

City State

Phone Number

CF-AA 2505, PDF 03/2008

HIPAA AUTHORIZATION FORM

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

Patient Name:

Patient Birth Date:

I, [Name of Patient] hereby authorize any physician, hospital, nursing facility, clinic, treatment center,

therapist, or other health care professional or provider who has treated me to disclose any and all of

my protected health information to Care Coverage, a division of R1, to assist me in applying for health

insurance coverage. I authorize Care Coverage to use and disclose my protected health information to

provide me this assistance.

The protected health information that is covered by this authorization includes (a) all my diagnostic

and treatment records, including any and all records related to my diagnosis or treatment of drug or

alcohol abuse, mental illness, or human immunodeficiency virus (HIV); and (b) all records related to

payment for my health care items or services.

This authorization shall be in force and effect for one year.

I understand that I may revoke this authorization at any time by sending written notice of revocation to

R1 Care Coverage at 26533 Evergreen Rd., Suite #700, Southfield, Michigan 48076. I understand that a revocation is not effective to the extent that Care Coverage or any health care provider has already relied upon my authorization for the use or disclosure of my protected health information.

I understand that information used or disclosed pursuant to this authorization may be disclosed by the

recipient and may no longer be protected by federal or state law.

My health care provider(s) will not condition my treatment on whether I provide authorization for the

requested use or disclosure.

Signature of Patient

Date

1

AUTHORIZATION OF PATIENT REPRESENTATION AND RELEASE OF INFORMATION

FROM: (PATIENT’S NAME) _____________________________________________

I hereby designate Care Coverage a service of R1 RCM Inc., its agents and employees (“Care Coverage a service of R1 RCM”)

to act on my behalf solely for the purpose of obtaining or modifying health care coverage for me and/or members of my

household before any health care provider, financial institution, life insurance company, place of employment, county/state

Department of Human Services, the Social Security Administration (and any legal counsel I may engage to represent me in a

Social Security Administration case), mental health institution and the Veterans Administration.

I expressly consent to the disclosure and release of the following information to Care Coverage a service of R1 RCM by any of

the person(s) and/or organization(s) named above:

1) Medical records, including psychiatric /mental health reports, reports relating to drug, alcohol, and HIV/AIDS;

2) Financial information, including bank statements, life insurance policies, and employment/payroll documentation;

and

3) Other documents and information pertaining to me and/or members of my household that may be relevant to health

care coverage.

I authorize Care Coverage a service of R1 RCM to take any and all steps to obtain a) health care coverage for me and/or members

of my family and b) the documentation needed to secure such coverage. I understand that Care Coverage a service of R1 RCM

makes no guarantees or warranties that it will be able to secure health insurance/Medicaid/Medicare coverage for me, and I

understand that even if coverage is secured, I will remain responsible for any and all unpaid balances for health care services

rendered.

I further authorize Care Coverage a service of R1 RCM to disclose and/or release information they receive from any of the

person(s) and/or organization(s) named above solely for the purpose of modifying or obtaining healthcare coverage for me and/or

members of my household.

I have had full opportunity to read and understand the contents of this authorization, and I confirm that the contents are consistent

with my direction to the person(s) and/or organization(s) named above and to Care Coverage a service of R1 RCM. I understand

that by signing this authorization, I am confirming such person(s) and/or organization(s) may disclose and/or release my

information to Care Coverage a service of R1 RCM and that Care Coverage a service of R1 RCM may in turn disclose such

information for the limited purpose of modifying or obtaining health care coverage.

The authorizations will be in effect until health care coverage is approved, a final determination is made that I am not eligible for

any health care coverage, or I withdraw the authorizations contained in this document by providing written notice to Care

Coverage a service of R1 RCM.

______________________________ ____________

Patient Name (print) Signature Date

______________________________ _________________________________ _____________

Authorizing Person if other than Patient Signature Date

_____________________________________________________________

Street Address

_____________________ _____ _______________ ________________________

City State Zip Phone

________________________________ _____________________________________

Hospital / Admit Date Witness Signature (if patient unable to sign)

________________________________

R1 RCM, Inc. Representative

2

INSTRUCTIONS: Please provide two additional contacts that R1 RCM Inc. can speak to on your behalf regarding your health

insurance/Medicaid/Medicare case:

AUTHORIZATION TO DISCUSS HEALTH CARE COVERAGE

I hereby authorize R1 RCM Inc. to use or disclose information related to my health care coverage with the

individuals listed below. This authorization will be in effect until health care coverage is approved, a final

determination is made that I am not eligible for any health care coverage, or I withdraw this authorization by

providing written notice to R1 RCM Inc.

Name: ________________________

Relationship to Patient: ____________________________

Phone: _____________________________

Name: ________________________

Relationship to Patient: _____________________________

Phone: ____________________________

______________________________ ____________

Patient Name (print) Signature Date

______________________________ _________________________________ _____________

Authorizing Person if other than Patient Signature Date

_____________________________________________________________

Street Address

_____________________ _____ _______________ ________________________

City State Zip Phone

________________________________ _____________________________________

Hospital / Admit Date Witness Signature (if Patient unable to sign)

________________________________

R1 RCM, Inc. Representative

FINANCIAL ASSISTANCE AGREEMENT

Please read before signing. Initial the small line at the beginning of each paragraph.

All information obtained will be utilized by our Patient Accounts staff to help resolve your financial

obligation to St. Vincent’s HealthCare. All questions asked and information requested will be utilized to

determine eligibility for potential funding sources such as Medicaid, HCRA, etc. and remain confidential. I

CERTIFY I am uninsured or underinsured and the information I have provided is true and accurate to the best

of my knowledge. I will make application for ANY and ALL ASSISTANCE which may be available through

federal, state, local government and private sources to help pay this hospital bill and will take all action

necessary to obtain assistance from the above sources.

I understand that if I do not cooperate with St. Vincent’s HealthCare (Herein known as SVHC) within 45

days from the date of service in requesting ANY additional information, my application may be denied for

possible financial assistance. I hereby designate SVHC’s Patient Accounts Department as my representative to

act on my behalf and assist in the application process and/or appeal of my application for any medical

assistance program.

I authorize a representative from SVHC Patient Accounts to file an application which includes my

electronic signature, receive any and all information from the Department of Children and Families regarding

the status, disposition, eligibility or denial of my application for medical assistance and to file a Fair Hearing

Appeal against the Department of Children and Families if a disagreement arises with the disposition of the

application. I also grant permission for a Patient Accounts representative to assist in obtaining a certified

copy of a birth or death certificate for myself or a member of my immediate family in order to continue the

application process. A copy of the designation of representative shall remain in effect for one (1) year or until

otherwise advised by the SVHC Accounts Department or myself. I acknowledge receipt of Rights and

Responsibilities, if applicable.

I will ASSIGN to SVHC ALL FUNDS received from the above sources, which are provided to help with

the HOSPITAL BILL. I, on my own behalf, and for my immediate family member(s), authorized

representative(s), physician(s), counselor(s) (including clergy) and attorney(s), agree to hold and maintain in

strict confidence any written communications and/or oral discussions between me and SVHC, regarding

matters relating to services provided to me by SVHC.

I understand that the information which I submit is subject to verification by SVHC,

including credit reporting agencies, and subject to review by FEDERAL and/or STATE AGENCIES

and others as required. I AUTHORIZE my employer to release to SVHC proof of my income. I

UNDERSTAND that if any information I have given proves to be untrue, SVHC will re-evaluate my

financial status and take whatever action becomes appropriate.

I hereby certify that the above information is true and correct to the best of my knowledge. In

accordance with s.817.50 F.S., providing false information to defraud a hospital for goods and services is a

misdemeanor in the second (2nd) degree. St. Vincent’s HealthCare can require income tax information or

investigate wages with employer to validate eligibility.

Patient Signature: _ Date:

Guarantor if other than patient:

Hospital Representative:

Date:

Date:

RMS Admin

Rectangle

Affidavit of Support

I, ___________________________, declare that I am presently unemployed and

have received $_________ income for the past ________ months/years, from

__________ to __________.

I currently live at ____________________________________________________.

My food and living expenses are provided by ______________________________

who is my _____________________.

_______________________ ________ ______________________ ________

St. Vincent’s Medical Center PO Box 2982

Jacksonville, FL

(Patient Name)

(Start Date) (Ending Date)

(Address)

(Provider Name)

(Relationship to Patient)

(Patient Signature) (Provider Signature) (Date) (Date)

HOPE PROGRAM

HOMELESS ATTESTATION FORM

Patient Name: ______________________________ DOB: _______________________________

Last 4 of SSN: _______________ SSN Verified (Y/N): ____________

___ I am currently a homeless individual and am allowed to receive mail at the following

address:

_____________________________________________________________________________

_____________________________________________________________________________

___ I receive food stamps in the amount of $________________ per month.

___ I am unemployed and have had no income for the last _____ months.

PATIENT

I hereby attest that my response to the applicable preceding statement is true, complete and

accurate. By signing this Attestation, you certify that you have read this Attestation or that it

has been read to you and applied a valid, legal signature.

_______________________________ _____________ __________________________

Patient Signature Date Phone Number

Homeowner/Leasee

Please have the homeowner/leasee of the home where you are allowed to receive mail

complete this section:

I _____________________________ attest that _______________________ is currently

homeless and is allowed to receive mail at my home address listed above.

_______________________________ _____________ __________________________

Resident Signature Date Phone Number