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Application for Norton Healthcare Financial Assistance

At Norton Healthcare, financial assistance for hospital-based charges is available to anyone who meets the eligibility requirements for total gross income, total resources, and then furnishes documentation to confirm this information. Financial assistance is provided for hospital-based charges at any of the following locations:

  • Norton Hospital
  • Norton Audubon Hospital
  • Norton Brownsboro Hospital
  • Norton Suburban Hospital
    • Kosair Children's Hospital
    • Kosair Children's Medical Center - Brownsboro
    • Norton Diagnostic Center - Brownsboro
    • Norton Diagnostic Center - Dupont

    Please fill out the information below and you will receive a response from our Financial Assistance department within seven calendar days. Please provide all the information requested so that we may accurately assess your need for assistance.

    Note: The information you provide is encrypted and submitted securely. It is only used for the purpose of qualification for financial assistance. Please read our privacy policy to learn more.

    * Indicates required information
    Patient Name * 
    Street Address 1 * 
    Street Address 2 
    City * 
    State * 
    Zip * 
    Phone Number
    (xxx-xxx-xxxx) * 
    Alternate Phone Number
    If no alternate phone number, please enter NONE. * 
    Email * 
    Patient Account Number 
    Employer Name
    (If patient is a child, enter parent's employer.)
    If unemployed, please enter UNEMPLOYED. * 
    Employer Phone Number
    If unemployed, please enter NONE. * 
    Spouse's Employer 
    Spouse's Employer Phone Number
    Total number of people in the patient's household (including the patient) * 
    Monthly Income
    What is your monthly income from the following sources? 
    Patient's Income (or parent's, if patient is a child) 
    Spouse's Income 
    Child Support/Alimony 
    Social Security 
    Food Stamps 
    Other Income
    Please list all additional income sources and monthly amount(s). 
    Monthly Expenses
    What are your monthly expenses? 
    Food and Supplies 
    Hospital Insurance Premiums 
    Prescribed Medicine 
    Other Expenses
    Please list all additional expenses and monthly amount(s). 
    What is the value of resources you have available to you? 
    Checking and Savings Account
    If you DO NOT have a checking or savings account, please enter NONE. * 
    Stocks and Bond Values
    If you DO NOT have stocks and bonds, please enter NONE. * 
    Other Resources
    Please list all additional resources and value(s). 
    Mortgagee Name 
    Current Value/Equity 
    Auto #1 
    Current Value/Equity 
    Auto #2 
    Current Value/Equity 
    Other Property/Autos
    Please list any additional properties or autos that you have. 
    Medical Expenses 
    Medical Expense #1 
    Hospital/Doctor's Name 
    Balance Owed 
    Monthly Payments 
    Medical Expense #2 
    Hospital/Doctor's Name 
    Balance Owed 
    Monthly Payments 
    Medical Expense #3 
    Hospital/Doctor's Name 
    Balance Owed 
    Monthly Payments 
    Medical Expense #4 
    Hospital/Doctor's Name 
    Balance Owed 
    Monthly Payments 
    Additional Medical Expenses
    Please list any additional medical expenses you have. 
    Prior to submitting, please read the paragraphs below and then check the box and enter your name if you agree to the certification. 

    I hereby agree to furnish Norton Healthcare with the information necessary to determine my eligibility for assistance with the medical bills resulting from the services I have received at their facilities. I understand that failure to complete and return this form within 10 (ten) days from the date it is requested by Norton Healthcare may result in the denial of my request for assistance. I understand that my physicians and other health care providers may have financial assistance policies that could assist me with the medical bills from those providers. As such, I authorize Norton Healthcare to provide a copy of my application to those providers who request it to assist them in determining whether I qualify for benefits under their financial assistance programs.

    I certify that the information provided by me in this application is correct and true to the best of my knowledge and belief. I understand that if I give false information or withhold information in applying for assistance, my application will be denied and Norton Healthcare will continue to pursue collection of any outstanding balance due. In that instance, I may also be subject to prosecution for fraud. I agree to notify Norton Healthcare of any changes to the information provided in this form including address, telephone number, and income.

    By checking here I certify that I have read and understand the above paragraphs, and that I request to be considered for financial assistance for hospital charges at Norton Healthcare. * 
    Responsible Party Name * 
    Authentication * 

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