Fill Out Your Robert Wood Johnson Hospital Letterhead Form
When navigating healthcare challenges, understanding the necessary steps to secure assistance can feel overwhelming. The Robert Wood Johnson University Hospital Letterhead form plays an essential role in this process by collecting vital information to determine eligibility for financial assistance. This form outlines the office hours for immediate inquiries and encourages applicants to gather various documents needed for their interview with a financial counselor. Identifying yourself and your family is crucial, as the form outlines specific identification requirements, which include documents like driver's licenses and social security cards. Additionally, applicants must provide proof of residency and submitted income data to assess their financial situation adequately. Income documentation must cover recent sources, including pay stubs and letters from employers, while details of liquid assets also need to be verified. With provisions in place for Medicaid eligibility assessments and checks on insurance coverage, this comprehensive form streamlines the application process for individuals seeking support. All necessary information must be included when applying; leaving out crucial details may delay the assistance sought. By ensuring that all documentation is accurate and complete, applicants can better navigate their healthcare options with confidence.
Robert Wood Johnson Hospital Letterhead Example
OFFICE HOURS: (732)
ROBERT WOOD JOHNSON UNIVERSITY HOSPITAL
120 ALBANY ST
6TH FLOOR, TOWER TWO
NEW BRUNSWICK, NJ 08901
charity.care@rwjuh.edu
THE REQUESTED INFORMATION BELOW MUST BE PROVIDED AT THE TIME OF YOUR INTERVIEW WITH A FINANCIAL COUNSELOR.
***ADDITIONAL INFORMATION MAY BE REQUESTED AFTER THE APPLICATION IS REVIEWED. ***
***PLEASE NOTE THAT ANY AND ALL INFORMATION BEING PRINTED FROM THE INTERNET, MUST BE VERIFIED BY A SIGNATURE AND STAMP FROM THAT COMPANY.***
PROPER IDENTIFICATION (SUPPLY ONE OF THE FOLLOWING FOR EACH FAMILY MEMBER) *** If you are a full time college student 21 yrs or younger you must provide all documents for both parents as well. They will be included in your family size as well as any sibling who is a full time student 21 yrs or younger ***
1. Driver’s License |
2. Social Security Card |
3. Valid Passport |
4. Birth Certificate |
PROOF OF NEW JERSEY RESIDENCY: (FOR THE MONTH OF YOUR REQUESTED SERVICE). You must supply one of the below required documents.
1. Utility Bill |
2. Copy of Lease or Deed |
3. Driver’s License |
4. Letter from individual stating that you live with |
|
|
|
him/her |
INCOME:
Actual gross income for the month immediately preceding the date of service or three month’s income immediately preceding service:
a)Pay stubs, unemployment stubs, disability, child support.
b)A letter from employer(s) on company letterhead (INCLUDING Name, Address and Telephone number) – Letter must state the Gross Income, also needs to state if covered by health insurance.
c)Copy of social security and/or pension award letter.
d)If not employed and have no income, must supply a letter from person supporting you.
e)If you receive financial aid for schooling you must supply the financial aid award letter for your last 2 semesters immediately preceding your date of service.
LIQUID ASSETS:
You must provide copies of any checking and savings accounts, IRA’s, CD’s, stocks and/or bonds, or any other account which can be readily converted into cash. All account statements must be valid for the date of service in question.
MEDICAID ELIGIBILITY:
If you are a under the age of 18, over the age of 65, Blind or Disabled or pregnant- You must show proof that you were screened for eligible Medicaid programs.
COPY OF ALL PAGES YOUR COMPLETED TAXES AND W2 FOR THE PRIOR YEAR
COPIES OF ANY AND ALL INSURANCE CARDS FOR EACH FAMILY MEMBER
Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732)
New Jersey Hospital Care Assistant Program
APPLICATION FOR PARTICIPATION
PROOF OF IDENTIFICATION, PROOF OF INCOME AND PROOF OF ASSETS MUST ACCOMPANY THIS APPLICATION
SEND COPIES OF ALL REQUESTED DOCUMENTS; DO NOT SEND ORIGINAL DOCUMENTS AS THEY WILL NOT BE RETURNED.
SECTION I – Personal Information
1. |
PATIENT NAME |
|
|
|
|
|
2. |
SOCIAL SECURITY NUMBER |
|
|
________________________________________ ________________________________________ |
|
____ ____ ____ - ____ ____ - ____ ____ ____ _____ |
||||||||
(Last) |
|
|
(First) |
|
(M) |
|
|
|
|
|
|
|
|
|
|
|
|
||||
3. |
DATE OF APPLICATION |
|
4. INITIAL DATE OF SERVICE |
|
5. REQUESTED DATE OF SERVICE |
|
||||
__________/__________/__________ |
__________/__________/__________ |
|
__________/__________/__________ |
|||||||
|
Month |
Day |
Year |
Month |
Day |
Year |
|
Month |
Day |
Year |
|
|
|
|
|
|
|
|
|||
6. |
STREET ADDRESS OF PATIENT |
|
|
|
7. |
TELEPHONE NUMBER |
|
|||
8. CITY, STATE, ZIP CODE
9. FAMILY SIZE *
10. U.S. CITIZENSHIP |
|
|
Yes |
No |
Pending Application |
11. PROOF OF
Yes |
No |
12. NAME OF GUARANTOR (If other than patient)
SECTION II – Assets Criteria
13.Individual Assets:
14.Family Assets:
15.Assets Include:
A.Cash
B.Savings Accounts
C.Checking Accounts
D.Certificates of Deposit/I.R.A.
E.Equity in Real Estate (other than primary residence)
F.Other Assets (Treasury Bills, Negotiable Paper, Corporate Stocks and Bonds)
G.Total
*Family size includes, self, spouse, and any minor children. A pregnant woman is counted as two family members.
Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732)
SECTION III – Income Criteria
When determining eligibility for hospital care assistance, a spouse’s income and assets must be used for an adult; parent’s(s) income and assets must be used for a minor child. Proof of income must accompany this application. Income is based on the calculation of either twelve months, three months or one month of income prior to the date of service.
Patient/Family Gross Income equals the lesser of the following:
LAST 12 MONTHS |
|
LAST 3 MONTHS |
|
|
X 4 |
|
or |
|
|
|
|
|
|
|
16.SOURCES OF INCOME:
A.Cash
B.Public Assistance
C.Social Security Benefits
D.Unemployment & Workmen’s Compensation
E.Veteran’s Benefit
F.Alimony/Child Support
G.Other Monetary Support
H.Pension Payments
I.Insurance or Annuity Payments
J.Dividends/Interest
K.Rental Income
L.Net Business Income (self employed/ verified by independent source)
M.Other (strike benefits, training stipends, military family allotment, income from estates and trusts).
N.Total
LAST 1 MONTH
X 12
or
WEEKLY |
MONTHLY |
YEARLY |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
SECTION IV – Certification by Applicant
I understand that the information which I submit is subject to verification by the appropriate health care facility and the Federal or State Governments. Willful misrepresentation of these facts will make me liable for all hospital charges and subject to civil penalties.
If so requested by the health care facility, I will apply for governmental or private medical assistance for payment of the hospital bill. I certify that the above information regarding my family size, income and assets is true and correct.
I understand that it is my responsibility to advise the hospital of any change in status in regards to my income or assets.
17. SIGNATURE OF PATIENT OR GUARANTOR
18. DATE
Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732)
Date:
To Whom It May Concern:
This is to state that I ________________________________________ do NOT have the
following (please check off what you do NOT have):
__________ 1040 Income Tax (Federal) Year
Did Not File
Do not work, collect unemployment, disability or receive financial assistance.
Checking Account
Savings Account
CD’S/STOCKS/ I.R.A. PLANS/ 401K
Medical/Dental/No Fault Insurance
_________________________________________________
Signature
Additional Comments:
Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732)
Date:
To Whom It May Concern:
This is to state that I ________________________________________ do NOT have the
following (please check off what you do NOT have):
__________ 1040 Income Tax (Federal) Year
Did Not File
Do not work, collect unemployment, disability or receive financial assistance.
Checking Account
Savings Account
CD’S/STOCKS/ I.R.A. PLANS/ 401K
Medical/Dental/No Fault Insurance
_________________________________________________
Signature
Additional Comments:
Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732)
To Whom It May Concern:
I, the undersigned, ________________________________________ (relation to patient)
______________________________, provide the necessary room, board and other life essentials for
_____________________________________________________________ at my residence,
___________________________________________________________, and have been doing so from
___________________________ to ________________________________.
I am not responsible or able to pay for any hospital or other medical expenses for him/her.
_________________________________________________ ________________________
Signature
Date
Telephone #: (_____) ________________________
Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732)
Date: __________________________________
I__________________________________________ state that I am not married to my
son’s/daughter’s/children’s father and receive no financial support from him although he provides us with food and shelter.
Signature
I__________________________________________ state that I am not married to my
son’s/daughter’s/children’s father and receive no financial support for him/her/them.
Signature
I__________________________________________ state that I am not married to my
son’s/daughter’s/children’s father but I do receive financial support for him/her/them.
Signature
Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732)
Date of initial separation:
Legal residence of applicant:
Legal residence of spouse:
I, _____________________________________________, certify and attest to the truthfulness of the
following:
1.That my spouse and I are separated and no longer reside together.
2.That I have no access to the funds of my spouse.
3.That I receive no support or monies from my spouse.
4.That my spouse and I have no financial ties.
5.That my spouse and I do not mingle or join our funds in any way, including the filing of joint federal or state income tax returns.
Signature:Date:
Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732)
APPLICATION FOR FINANCIAL ASSISTANCE
I understand that the information which I submit is subject to verification by the appropriate health care facility and the Federal or State Governments. Willful misrepresentation of these facts will make me liable for all hospital charges and subject to civil penalties.
If so requested by the health care facility, I will apply for governmental or private medical assistance for payment of the hospital bill.
I certify that the above information regarding my family size, income and assets is true and correct.
I hereby certify that the information provided for purpose of creating a financial assistance/Charity Care application is correct to the best of my knowledge.
I understand that it is my responsibility to advise the hospital of any change in status in regards to my income or assets.
APPLICANT SIGNATURE |
DATE |
PARENT/GUARDIAN SIGNATURE |
DATE |
PROVIDER NAME: Robert Wood Johnson University Hospital
Robert Wood Johnson University Hospital ~ One Robert Wood Johnson Place ~ New Brunswick, NJ 08901 ~ (732)
Form Characteristics
| Fact Name | Details |
|---|---|
| Hospital Name | Robert Wood Johnson University Hospital |
| Location | 120 Albany St, 6th Floor, Tower Two, New Brunswick, NJ 08901 |
| Contact Number | (732) 418-8450 |
| Office Hours | 9:00 AM - 4:30 PM, No appointment required |
| Email for Assistance | charity.care@rwjuh.edu |
| Identification Requirements | Proof of identification includes a Driver’s License, Social Security Card, Valid Passport, or Birth Certificate. |
| Residency Proof | Documents like a Utility Bill, Lease, or Driver’s License must be provided to prove New Jersey residency for the month of service. |
| Income Documentation | Gross income from the month before the service must be supplied, along with supporting documents such as pay stubs or employer letters. |
| Legal Reference | Related to the New Jersey Hospital Care Assistant Program and applicable under New Jersey state law. |
Guidelines on Utilizing Robert Wood Johnson Hospital Letterhead
Once you have gathered the necessary documents, you can begin filling out the Robert Wood Johnson Hospital Letterhead form. It is important to ensure that all required information and documentation are prepared for your interview with a financial counselor. This will help facilitate the process and make sure that your application is complete.
- Enter the PATIENT NAME at the top of Section I.
- Provide the SOCIAL SECURITY NUMBER in the designated space.
- Fill in the DATE OF APPLICATION as well as the INITIAL DATE OF SERVICE and REQUESTED DATE OF SERVICE.
- Complete the STREET ADDRESS OF PATIENT, TELEPHONE NUMBER, and CITY, STATE, ZIP CODE.
- Indicate the FAMILY SIZE by counting all family members, including yourself, spouse, and minor children.
- Mark your U.S. CITIZENSHIP status with a check in the appropriate box.
- Answer whether you can provide PROOF OF 3-MONTH RESIDENCY in New Jersey.
- If applicable, enter the NAME OF GUARANTOR if it differs from the patient.
For Section II, you will need to list both Individual Assets and Family Assets.
- Detail the Individual Assets including cash, savings, checking accounts, IRAs, CDs, equity in real estate, and any other assets.
- Similarly, record the Family Assets in the same categories as mentioned above.
Then, proceed to Section III, Income Criteria.
- List all sources of income, including public assistance, social security benefits, unemployment, and other forms of monetary support.
- Make sure to provide proof of income based on the last 12 months, 3 months, or monthly income prior to the service date.
Finally, complete Section IV by signing the certification statement indicating that you understand the information you have provided is subject to verification.
- Sign where requested as the PATIENT OR GUARANTOR.
- Record the DATE next to your signature.
Before submitting, ensure you attach copies of all required documents, as original documents will not be returned. Verify that every section of the form is completed to ensure a smooth processing of your application.
What You Should Know About This Form
What is the purpose of the Robert Wood Johnson Hospital Letterhead form?
The Robert Wood Johnson Hospital Letterhead form is primarily used to apply for the New Jersey Hospital Care Assistant Program. This program assists individuals who need financial aid for hospital services. To ensure eligibility, applicants must provide detailed information regarding their personal identification, income, residency, and assets. Completing this form accurately is crucial for the consideration of financial assistance from the hospital.
What information is required when applying for assistance?
Applicants must provide various types of documentation to verify their identity and financial situation. This includes proper identification for each family member, proof of New Jersey residency, current income documentation, and a list of liquid assets. Common accepted documents include a driver's license, utility bill, pay stubs, tax returns, and bank statements. Additional documents may be requested after the application review if further clarification is needed.
How can I submit my application and documents?
To submit the application, follow these steps: complete the Robert Wood Johnson Hospital Letterhead form, gather copies of all required documents, and ensure that they are valid for the date of service. Unlike original documents, copies should be sent since originals will not be returned. The completed application and supporting documents can be sent directly to the hospital’s financial assistance department via mail or, if permitted, through designated electronic methods.
What happens after I submit my application?
After submission, the application will be reviewed by a financial counselor. The counselor may reach out to you for any clarifying information or additional documentation that might be needed. If approved, you will be informed of the details regarding your financial assistance. It is also essential to notify the hospital of any changes in income or asset status that may occur after your application is submitted, as this can affect your eligibility.
Common mistakes
Completing the Robert Wood Johnson Hospital Letterhead form can be a straightforward process, but various mistakes can complicate matters. One common mistake is failing to include all required identification documents. Patients must provide proper identification for each family member. This includes a driver's license, social security card, passport, or birth certificate. Neglecting to supply these essential documents can delay the application process.
Another frequent error occurs in the income documentation section. Applicants often forget to provide three months of income verification, which can include pay stubs or letters from employers. Incomplete income records may lead to an assessment based on inaccurate financial information. It is vital to include all sources of income, as omitting any can jeopardize eligibility.
Not providing proof of New Jersey residency is another mistake applicants tend to make. The form requires residents to submit a utility bill, lease, or driver's license that reflects their current address. Failing to do so may result in the rejection of the application.
Additionally, many people overlook the need for liquid asset documentation. Applicants are required to present copies of bank statements or other financial asset records. Without this information, the review process can be hindered, and the request for assistance may be postponed.
Some individuals mistakenly ignore the requirement to sign and date the application. Failing to include a signature can render the entire application void. Applicants should ensure that all mandatory signatures are present before submission.
Another misstep is not verifying information from printed sources. The form emphasizes that anything obtained online must be signed and stamped by the issuing organization. Submitting unofficial documents can lead to complications during the processing stage.
Miscalculations concerning family size are often problematic. Properly counting family members is essential, especially for pregnant women, who should be counted as two. Errors in family size can affect the evaluation of eligibility.
Many applicants also misunderstand the Medicaid eligibility requirements. Those under 18 or over 65, as well as pregnant individuals or those who are disabled, need to provide proof of screening for Medicaid programs. Ignoring this step can hinder access to crucial assistance.
Finally, applicants sometimes fail to provide complete tax documentation. The form requires copies of all pages of completed taxes and W-2 forms from the prior year. Omitting any documents could jeopardize the evaluation of the application.
Documents used along the form
When applying for financial assistance through the Robert Wood Johnson Hospital Letterhead form, several other documents are often required to ensure a comprehensive evaluation of your eligibility. Below is a list of commonly needed forms and documents that complement your application. Each item is important for verifying your identity, financial situation, and residency status.
- Proof of Identification: This may include documents such as a Driver’s License, Social Security Card, valid Passport, or Birth Certificate. They verify the identity of each family member applying for assistance.
- Proof of Residency: Required to confirm residence in New Jersey, acceptable documents include a recent Utility Bill, Lease Agreement, or a personal letter confirming your living situation.
- Income Verification: This is essential to demonstrate your financial need. You may submit recent pay stubs, a letter from your employer, or a copy of a Social Security award letter.
- Liquid Assets Documentation: Provide bank statements or records of other liquid assets such as stocks or bonds. This helps to understand your financial resources.
- Medicaid Eligibility Documentation: If applicable, this includes proof of screening for eligible Medicaid programs, particularly for applicants under 18, over 65, or those who are disabled.
- Tax Documents: A copy of your completed tax returns and W-2 forms for the previous year may be necessary for comprehensive financial evaluation.
- Insurance Cards: Include copies of health insurance cards for each family member. This shows existing coverage and potential resources for medical expenses.
- Financial Aid Award Letters: For students, documentation of financial aid received for the last two semesters is vital for assessing support during education.
- Letter of Support: If you have no income, a letter from the individual supporting you is required, confirming your reliance on them financially.
- Income Declaration Letter: A formal statement outlining that you have no taxable income or financial resources is often requested when individuals are unemployed or not receiving assistance.
Gathering these documents ahead of time will help facilitate a smoother application process. Ensure that all information is accurate and up to date to support your request effectively.
Similar forms
The Robert Wood Johnson Hospital Letterhead form serves an essential function in managing patient financial assistance. Its detailed nature allows it to draw parallels with several other key documents. Here are four documents that share similarities with this form:
- Medicaid Application Form: Like the hospital letterhead form, the Medicaid application requires detailed personal and financial information. Both documents collect proof of identity, residency, and income to determine eligibility for benefits.
- Financial Aid Application (FAFSA): Just as the hospital form seeks financial documentation, the FAFSA requires applicants to provide information about income and assets. Both forms aim to determine the level of financial support or assistance an individual may qualify for.
- Charity Care Application: Similar to the Robert Wood Johnson Hospital form, the charity care application requires comprehensive details about a family's financial situation, including income proof, asset documentation, and identification. The goal remains to assess eligibility for assistance programs.
- Insurance Claim Form: Both the insurance claim form and the hospital letterhead form ask for personal identification and detailed financial information. Each aims to facilitate the processing of claims or financial assistance requests, ensuring all necessary information is gathered for evaluation.
Dos and Don'ts
When filling out the Robert Wood Johnson Hospital Letterhead form, it is important to do certain things correctly while avoiding common pitfalls. Below is a list of five do's and don'ts to guide you through the process.
- Do ensure you provide accurate and complete personal information. Missing details can lead to delays in processing your application.
- Do include appropriate identification for each family member. Acceptable forms include a driver’s license or social security card.
- Do have proof of income prepared. This can include pay stubs or a letter from your employer.
- Do verify all documents printed from the internet. A signature and stamp from the issuing company are required.
- Do check the office hours before visiting to ensure you receive the assistance you need.
- Don't submit original documents. Only copies are accepted, and originals will not be returned.
- Don't forget to include proof of New Jersey residency. Acceptable documents can be a utility bill or a copy of your lease.
- Don't underestimate the importance of family size. Include all qualifying family members, such as dependents and students, in your application.
- Don't ignore the requirement for Medicaid eligibility if applicable. Under age 18, over 65, or pregnant individuals must provide proof.
- Don't neglect to sign and date your application. Your signature certifies the accuracy of the information provided.
Misconceptions
Misconception 1: The letterhead form is only for low-income individuals.
While the form is aimed at providing hospital care assistance, it's not solely limited to those with very low incomes. Individuals from various economic backgrounds may need assistance, especially in times of unexpected medical expenses.
Misconception 2: You must have all documents ready at the first visit.
It's understandable to feel overwhelmed by the documentation required, but you are not expected to have every single document at the time of your initial interview with a financial counselor. You will still be able to start the application process, but be prepared that additional information may be requested later.
Misconception 3: Only residents of New Jersey can apply.
This is a common misunderstanding. Even if you reside in New Jersey temporarily, you may still be eligible for assistance, depending on your situation. Students or individuals residing temporarily for work may also qualify.
Misconception 4: Income is the only factor for eligibility.
While income is a significant factor in determining eligibility, the form also looks at other aspects, like liquid assets and proof of residency. It's important to gather information on all relevant factors, not just income.
Key takeaways
Here are some key takeaways regarding the Robert Wood Johnson Hospital Letterhead form:
- Provide Required Information: Ensure that all requested information is available at the time of your interview with a financial counselor. Incomplete applications may lead to delays.
- Verify Your Documents: Any information printed from the internet must be verified with a signature and stamp from the respective company. This helps maintain the integrity of submitted information.
- Identification is Crucial: Each family member requires proper identification. Acceptable forms include a driver’s license, social security card, valid passport, or birth certificate.
- Document Residency and Income: Proof of New Jersey residency and income from the previous month or three months is necessary. Gather items like utility bills, pay stubs, or employer letters for submission.
- No Originals: When submitting your documents, remember to send copies only. Original documents will not be returned, so keep your important paperwork safe.
Browse Other Templates
Fort Hood Vehicle Safety Checklist,III Corps Vehicle Examination Form,Fort Hood Auto Compliance Report,Fort Hood Vehicle Inspection Report,III Corps Motor Vehicle Assessment,Fort Hood Driver Safety Evaluation,Fort Hood Vehicle Condition Survey,III Co - This form is used for vehicle inspections at Fort Hood.
What Is Form 8283 - This worksheet assists taxpayers in calculating non-cash charitable contributions for tax purposes.