The Children’s Institute of Pittsburgh
FINANCIAL ASSISTANCE

Application
page 2 of 2

This electronic version of the Financial Assistance Application has been made available for convenience and readability. Once all fields are completed, please print, sign and mailyour completed applicationalong with copies of your proof of income documents to:

The Children’s Institute of Pittsburgh

Tracey Watkins

1405 Shady Avenue

Pittsburgh, PA 15217

Name of Patient:
Patient’s Date of Birth: / Click here to enter a date. / Patient’s Social Security Number:
Address:
Number and Street / City / State / Zip / County
Daytime Phone Number: / Alternate Phone Number:

Requested Services: Check the services for which you are requesting financial assistance:

InpatientOutpatient
Person responsible for the bill and relationship to the patient:
Responsible person’s employer name:
Number and Street / City / State / Zip / County
Responsible person’s address if different from above:
Is the patient covered under health insurance: / Yes No
Have you applied for Medical Assistance / Yes No / Application Date: / Click here to enter a date.
If denied, please enclose copy of the Letter of Denial
Is the patient covered under a trust: / Yes No / Name of Trust:
Manager of the Trust:
Name / Address / Phone

Household Information: List ALL members of your household who were claimed on you most recent IRS form 1040.

Names / Relationship to Patient / Age
Total number of household members (including the patient):

Monthly household income: Give gross monthlyincome for all household members.

Also attach any proof of income documents (list not all inclusive: pay stubs for last 3 months, W-2, last year’s tax return, Schedule C or profit/loss statement if self employed, award letters from social security, unemployment or worker’s compensation)

Wages/self employment / $
Social Security / $
Dividends and Interest / $
Rents and royalties / $
Unemployment / $
Alimony and child support / $
Other income / $
Total Monthly Family Income / $

Exceptional expenditures within the last 12 months (ex: special needs equipment, accessibility modifications)

Family Member / Dollar Amount
$
$
$
$

Certification and Authorization to release information and conditions for financial aid:

I understand the information I provide will be used only to determine financial responsibility for patient liability at The Children’s Institute of Pittsburgh and will be kept confidential. I understand that the materials I send to prove my income will not be returned. I further understand that the information which I submit concerning my annual family income and family size is subject to verification by The Children’s Institute. I understand that if any information given is determined to be false, it may result in reversing the financial assistance approval and I will be liable for the full amount of the liability.

My signature authorizes release to any third party with legitimate interest such information as may be necessary to the completion of insurance application and verification of financial information.

Signature:
Relationship to patient: / Date: / Click here to enter a date. /
Approved for: / % / Estimated Amount: / $ / Director of Patient Access / Date / Click here to enter a date. /
VP Clinical Operations / Date / Click here to enter a date. /
VP of Finance / Date / Click here to enter a date. / President / Date / Click here to enter a date. /