AULTMAN ORRVILLE HOSPITAL

"You must be at or below 100% of the Federal Poverty Income Guidelines."

documented · checked 2026-10-10 · Financial Assistance Summary Aultman Hospital

"Patients that are insured and their gross family income is at or below 200% of the Federal Poverty Income guidelines may be eligible to receive financial assistance."

documented · checked 2026-10-10 · TITLE: Financial Assistance Aultman ...

"Please provide the following information for family members living in the home. Family members include you, your spouse, and/or natural or adopted children under age 18. For patients under the age of 18, list the patient, the patient’s natural or adoptive parent(s) (regardless of whether or not the parent lives in the home with the patient) and the patient’s siblings (natural or adoptive) who live in the home. Name (First, Last) Age Relationship to Patient Regular Wages, Pensions, Social Security, SSI, V A Benefits How Often weekly/ every 2 weeks/ monthly Type of Income Total Gross Income* for 3 months prior to service date *Prior to Deductions Total Gross Income* for 12 months prior to service date *Prior to Deductions Jane Doe (example) 43 Self $200.00 Weekly Unemployment $2,400.00 $9,600.00 (Patient) Total Family Size: Total Income: NOTE: If you or any family members have no income, you must state “0”. If you reported zero “0” income, please explain below how basic food and housing needs were provided prior to the date of service: . By my signature below, I affirm that to the best of my knowledge the answers on this application are true. I understand an authorized Aultman Health Foundation representative may contact me for additional information or use a third-party organization to verify the financial information stated on this application. Date: _____________ Date: Applicant Signature: Patient Outreach Representative: _____________________________________________________________ Form 1549 (93353) R: 04/04/2024  Yes  No  Yes  No  Yes  No  Yes  No 1. Were you an Ohio resident at the time of your hospital service? 2. Did you have health insurance other than Medicaid at the time of your service? 3. Were you an active Medicaid/DMA recipient at the time of your service? If yes, Medicaid recipient ID number: ____________________________ 4.  Single  Married  Separated (if separated, spouse’s income is still required). 5. Do you have assets? (If yes, indicate below) VALUE OF ASSETS: Checking Account Balance: $___________________________ Savings Account Balance: $____________________________ Savings Account Interest Rate: ______% Total Investments: $_________________________________ Investment Description: ______________________________________________________________ Other Asset Value: $_________________________________ Other Asset Description (car, boat, etc.): ________________________________________________ Other Income: $_____________________________________ Other Income Description (401k/IRA withdrawal, etc.): ______________________________________ TOTAL MONTHLY EXPENSES (rent/mortgage, car payment, utilities, food, etc.): $_____________________________________________________________________  Check if you receive Social Security income and include current year benefit letter I I I I SIGN"

documented · checked 2026-10-10 · [PDF] FINANCIAL ASSISTANCE APPLICATION - Aultman Hospital

"Completed applications and accompanying documentation should be submitted to: Aultman Outreach Department, 2600 Sixth Street, S.W., Canton OH 44710. Questions regarding this policy or the FAP Application should be directed to the Aultman Outreach Department at (330) 363-2200 or by email at patientoutreach@aultman.com."

documented · checked 2026-10-10 · TITLE: Financial Assistance Aultman ...

"Refraining from engaging in any Extraordinary Collection Activities for a minimum of 120 days from the date of the first post-discharge billing statement unless a final eligibility determination has been made under this policy pursuant to a completed FAP Application."

documented · checked 2026-10-10 · TITLE: Financial Assistance Aultman ...

"Questions regarding this policy or the FAP Application should be directed to the Aultman Outreach Department at (330) 363-2200 or by email at patientoutreach@aultman.com."

documented · checked 2026-10-10 · TITLE: Financial Assistance Aultman ...