HCAP FORM
230 Medical Center Drive
Seaman, OH 45679
937-386-3400
Date of Request:______________________
I request Adams County Regional Medical Center to review my eligibility for uncompensated services.
These services were done at Adams County Regional Medical Center. I understand that:
1. I must give the information below for this review
2. Adams County Regional Medical Center may verify the information
3. If I give false information I will be denied uncompensated services
4. Denial makes me liable for payment for services provided
Name: _________________________ __________________ _________________________ __________________
First
Middle
Last
Phone number
Address:___________________________________________________________________________________________
Number & Street
City
State
Zip Code
Occupation: _____________________________ Employer:
_________________________________________________
List family income for the LAST 3 MONTHS. Income verification may be required if the information provided
is in question. If you reported $0 income, please write a brief explanation on the back of this form or on an
attached sheet. A family shall include parent(s), their spouses(s), all children, natural or adoptive, under 18, who
live in the home.
Wages
Farm or self employment
Public Assistance
Social Security
Unemployment Compensation
Workers Compensation
Strike Benefits
Alimony
Child Support
Military Family Allotments
Pensions
Income from Dividends, Interest, Rent
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
Total Annual Income:__________________________
Family Members: Parent(s), their spouses(s), all children, natural or adoptive, under the age of 18, who live in the home.
Name
Age
Relationship
Type of Service Required: _________________________________________________________________
I affirm that the above information is true and correct to the best of my knowledge.
Signature:__________________________________________________ Date:_________________________
“Affiliated with The Christ Hospital”
In order to process your account for Uncompensated Services, I will need the following:
 A completed Ohio Health Care Assurance Program Form
If you have any questions, please call the Credit/Collections Department at 937-386-3449.
IMPORTANT INFORMATION
PLEASE READ!!
Effective with services on or after May 22, 1992, Adams County Regional Medical Center
provides to patients who qualify basic, medically necessary hospital services at no charge.
The patient must meet the following guidelines:
1) Patient is a resident of the State of Ohio.
2) Patient’s total family income before taxes must be at or below the federal poverty
guidelines as listed below. A family shall include parent (s), their spouse (s), and all
children, natural or adoptive, under the age of 18 who live at home.
FPL—Federal Poverty Level
FAP—Financial Assistance Program
FINANCIAL ASSISTANCE POVERTY GUIDELINES FOR 2011 (EFFECTIVE 01/20/2011)
FAMILY 100% FPL 120% FPL 140% FPL 160% FPL 180% FPL 200% FPL 220% FPL 240% FPL 260% FPL 280% FPL 300% FPL
UNIT
1
2
3
4
5
6
7
8
EACH
ADD'L
HCAP
FAP 100% FAP 90%
FAP 80%
FAP 70%
FAP 60%
FAP 50%
FAP 40%
$10,890
$14,710
$18,530
$22,350
$26,170
$29,990
$33,810
$37,630
$13,068
$17,652
$22,236
$26,820
$31,404
$35,988
$40,572
$45,156
$15,246
$20,594
$25,942
$31,290
$36,638
$41,986
$47,334
$52,682
$17,424
$23,536
$29,648
$35,760
$41,872
$47,984
$54,096
$60,208
$19,602
$26,478
$33,354
$40,230
$47,106
$53,982
$60,858
$67,734
$21,780
$29,420
$37,060
$44,700
$52,340
$59,980
$67,620
$75,260
$23,958
$32,362
$40,766
$49,170
$57,574
$65,978
$74,382
$82,786
$26,136
$35,304
$44,472
$53,640
$62,808
$71,976
$81,144
$90,312
$3,820
$4,584
$5,348
$6,112
$6,876
$7,640
$8,404
$9,168
FAP 30%
FAP 20%
FAP 10%
$28,314 $30,492 $32,670
$38,246 $41,188 $44,130
$48,178 $51,884 $55,590
$58,110 $62,580 $67,050
$68,042 $73,276 $78,510
$77,974 $83,972 $89,970
$87,906 $94,668 $101,430
$97,838 $105,364 $112,890
$9,932
$10,696
$11,460
Examples:
1. A family of two (2) with an annual income of $35,000, would quality for 40% Sliding Fee mark off.
2. A family of four (4) with an annual income of $25,000 would qualify for a 100% Sliding Fee mark off.
Revised: 02/2011
“Affiliated with The Christ Hospital”