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:
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.
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.
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