The Center for the Performing Artist at NewYork-­‐Presbyterian Hospital/Weill Cornell Medical Center Charity Care/Financial Aid Application Form Please complete the application and attach all required documents and submit to the administrative office of the Center for the Performing Artist in advance of your visit. If relevant documentation listed below is not provided or your application is incomplete, we will be unable to process your application. To further assist us in processing your application for financial aid please provide copies of the documents indicated below which apply to your particular situation. • IRS forms: W-­‐2 or 1099 • Tax Return: U.S. Federal form 1040 or Country of Citizenship • Last 3 Payroll Statements or Unemployment Benefits Statements (evidence of start date) • Social Security Award letter • Mortgage Payment/Rent Receipt and/or Letter from whoever pays the rent or mortgage • Most Recent Bank and/or Brokerage Statements • Any Medicaid and/or Health Benefits Acceptance or Denial Letter • Any Document that relates to information provided on the application’s signature page, for example: Food Stamps, Public Assistance, Self Employment If you are under 21 (Twenty-­‐one) years of age, and/or you are a dependent of your parent(s)/guardian(s), then your parent or guardian must fill out the eligibility application form entitled APPLICATION FOR FINANCIAL AID AND SLIDING FEE SCALE and provide the necessary supporting documents. A phone number where you can be reached MUST BE PROVIDED, as well as complete addresses, including apartment numbers and letters. A note describing your situation may also be helpful, but copies of the documents listed above which apply to your situation are necessary to determine your or your children’s eligibility. If you are a student, please provide documentation of your student status. NOTICE TO PATIENTS IF YOU SUBMIT A COMPLETED APPLICATION INCLUDING INFORMATION OR DOCUMENATION NECESSARY TO DETERMINE ELEGIBILITY UNDER THE MEDICAL CENTER’S POLICY, YOU MAY DISREGARD ANY MEDICAL CENTER BILL UNTIL WE HAVE MADE A DECISION ON YOUR APPLICATION. The Center for the Performing Artist at NewYork-­‐Presbyterian Hospital/Weill Cornell Medical Center The Center for the Performing Artist at NewYork-­‐Presbyterian Hospital/Weill Cornell Medical Center Application for Financial Aid and Sliding Fee Scale Demographics Patient's Name Date of Birth Address and Apt # City State Zip Home Phone Cell Phone Employer Employer Address Employer Telephone Income: List combined income for self, spouse, and all other household members Total Last 3 Mo Total Last 12 Mo Wages Self Employment Earnings Public Assistance Social Security Unemployment/Workers Compensation Alimony Child Support Pensions Income from Dividends Resources (Bank accts, investments, loans) Total Family Size: Family members living in your household Name Age Relationship I hereby request that New York-­‐Presbyterian Hospital/Weill Cornell Medical Center make a written determination of my eligibility for financial aid. I understand that the information which I submit concerning my annual income and family size is subject to verification by the hospital. I also understand that if the information which I submit is determined to be false, such determination will result in a denial of financial aid and that I will be liable for charges for services provided. I affirm that the above information is true and correct to the best of my knowledge. Further, I hereby give my permission to New York-­‐Presbyterian Hospital to verify any information pertinent to this application. Date ___________________Signature of Applicant __________________________________ Completed application to be sent to: The Center for the Performing Artist at New York-­‐Presbyterian Hospital/Weill Cornell Medical Center, 1305 York Avenue, Suite Y515, New York, New York 10021 Telephone 646-­‐962-­‐5441 Fax 646-­‐962-­‐0100 Generally, patients will be encouraged to first apply for applicable insurance programs, such as Workers Compensation and no-­‐fault insurance, and those special programs listed below before being considered for Charity Care. MEDICAID: for certain individuals with low incomes and resources. CHILD HEALTH PLUS: for children under the age of 19, who are not eligible for Medicaid, regardless of immigration status. FAMILY HEALTH PLUS: for adults age 19 to 64 who are legal U.S. residents. MEDICAID MANAGED CARE: for Medicaid-­‐eligible individuals. For information about how you can apply for these programs, please call our Medicaid Eligibility Units at: (212) 746-­‐4250 (New York Presbyterian – Weill Cornell) (212) 305-­‐2974 (New York Presbyterian – Columbia/MSCHONY) (212) 932-­‐4511 (New York Presbyterian -­‐ The Allen Pavilion) (212) 746-­‐3733 (Payne Whitney -­‐ Manhattan) (914) 997-­‐5959 (Payne Whitney -­‐ Westchester) Sliding Fee Scale Patients who do not qualify for our Charity Care program or the Special Assistance Fund may be eligible for a sliding fee scale. To find out more information, call us at 646-­‐962-­‐ARTS. Before submitting the financial assistance application posted here please call our office to determine which program is best for you 646-­‐962-­‐ARTS.