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The UVA Financial Assistance form is a critical resource for individuals seeking financial aid for medical expenses at the University of Virginia Medical Center. This form requires applicants to provide comprehensive personal information, including their name, social security number, address, and details about their marital status. Applicants must also disclose their income and asset information in detail. This includes any monthly wages, unemployment benefits, and other sources of financial support. Additionally, applicants need to list all involved family members and their income sources. Documentation is essential to establish financial need, so the form outlines various types of paperwork that must be submitted alongside it. These may involve pay stubs, bank statements, and proof of government benefits, among other requirements. The form also includes a declaration section, whereby applicants affirm the accuracy of the information they provide. It serves as an important step toward accessing available financial assistance programs designed to help alleviate the costs associated with medical care.

Uva Financial Assistance Example

001FIN

APPLICATION FOR FINANCIAL ASSISTANCE

STEP 1: COMPLETE INFORMATION BELOW: (ALL QUESTIONS MUST BE ANSWERED)

PLEASE MAIL COMPLETED FORM TO: ATTENTION VERIFICATION DEPARTMENT BOX 800750

CHARLOTTESVILLE, VA 22908-0750 1-866-320-9659

PATIENT NAME:

 

 

 

SOCIAL SECURITY#(REQUIRED):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS:

 

 

 

BIRTH DATE:

 

 

 

 

 

 

 

 

 

CITY, STATE, ZIP:

 

 

 

MEDICAL RECORD NO:

 

 

 

 

 

 

 

 

 

HOME TELEPHONE NUMBER:

 

 

 

WORK TELEPHONE NUMBER:

 

 

 

 

 

 

 

 

 

MARITAL STATUS: (CIRCLE ONE)

SINGLE

MARRIED

DIVORCED

SEPARATED

WIDOWED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STEP 2: FILL OUT INCOME/ASSET INFORMATION: IF ADDITIONAL SPACE IS REQUIRED PLEASE ATTACH SEPARATE PIECE OF PAPER.

FAMILY MEMBERS –

INCLUDE SELF,

SPOUSE CHILDREN

UNDER 18

SEX

SOCIAL SECURITY # (REQUIRED)

BIRTH

DATE

RELATION

TO

PATIENT

MONTHLY GROSS

WAGES/

SOCIAL

SECURITY, ETC.

EMPLOYER

NAME

EMPLOYER PHONE NO.

DO YOU HAVE INSURANCE WHICH COVERS ALL OR PART OF THE COST OF PRESCRIPTION MEDICATIONS? YES / NO. IF YES LIST THE INSURANCE(S) NAMES BELOW WITH MEMBER IDS AND GROUP #S:

_____________________________________________________________________________________________________________________________

IF UNEMPLOYED, PROVIDE THE DATE EMPLOYMENT ENDED

 

 

. HAVE YOU APPLIED FOR UNEMPLOYMENT?

YES / NO

IF THERE IS NO REPORTED INCOME, HAVE YOU APPLIED FOR DISABILITY?

YES / NO ARE YOU PLANNING ON APPLYING? YES

/ NO

DOES ANYONE IN YOUR HOUSEHOLD RECEIVE ANY OF THE FOLLOWING: (PLEASE PROVIDE PROOF)?

 

CHILD SUPPORT

YES / NO AMOUNT $

__ _ ALIMONY: YES

/ NO AMOUNT $

 

 

 

 

 

 

 

 

 

 

 

 

 

CHECKING ACCOUNT NO:

 

 

 

BANK NAME:

 

 

 

 

BALANCE: $

 

YES / NO

(CIRCLE)

 

 

 

LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SAVINGS ACCOUNT NO:

 

 

 

BANK NAME:

 

 

 

 

BALANCE: $

 

YES / NO

(CIRCLE)

 

 

 

LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STOCKS, BONDS, IRA’S, 401K, CDs, ETC.

 

 

 

BANK NAME:

 

 

 

 

BALANCE: $

 

YES / NO

(CIRCLE)

 

 

 

LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DO YOU OWN OR CURRENTLY BUYING REAL ESTATE PROPERTY: YES / NO CITY/COUNTY:

 

__

_

TOTAL ACREAGE:

 

 

 

 

 

 

 

 

MORTGAGE AMOUNT: $____________ DO YOU LIVE ON THE REAL ESTATE PROPERTY: YES / NO

 

 

 

 

 

 

 

 

 

 

 

 

DO YOU HAVE LIFE INSURANCE FOR YOU OR ANY DEPENDENT OVER 21 WITH A CASH OR LOAN VALUE?

YES /

NO

(CIRCLE)

NAME OF LIFE INSURANCE CO:

POLICY NO:

CASH-IN VALUE: $

PERSONAL PROPERTY: YES / NO (CIRCLE ONE)

LIST ALL CARS, TRUCKS, MOTORCYCLES, CAMPERS, MOBILE HOMES, ETC.

 

IF APPLICABLE; DO YOU RESIDE IN YOUR MOBILE HOME: YES / NO

 

 

 

 

 

 

 

 

 

ITEM:

MAKE MODEL

YEAR:

OWNER:

AMOUNT OWED: $

VALUE: $

 

 

 

 

 

 

ITEM:

MAKE MODEL

YEAR:

OWNER:

AMOUNT OWED: $

VALUE: $

 

 

 

 

 

 

DECLARATION: THE INFORMATION PROVIDED ABOVE IS, TO THE BEST OF MY KNOWLEDGE AND BELIEF, COMPLETE, ACCURATE AND TRUE. I AUTHORIZE THE RELEASE OF ALL INFORMATION WHICH THE UVA MEDICAL CENTER MAY NEED TO DETERMINE WHETHER I QUALIFY FOR FINANCIAL ASSISTANCE THROUGH THE HOSPITAL’S INDIGENT CARE PROGRAM, ANY DRUG MANUFACTURER SPONSORED DRUG ASSISTANCE PROGRAM OR ANY OTHER FEDERAL OR STATE FUNDED MEDICAL ASSISTANCE PROGRAM, INCLUDING VERIFICATION OF MY SALARY OR WAGES, THE BALANCE OF ANY BANK ACCOUNTS THAT I MAINTAIN, THE CASH-IN VALUE OF ANY LIFE INS. POLICY, STOCKS OR BONDS WHICH I POSSESS, AS WELL AS THE VALUE OF ANY REAL OR PERSONAL PROPERTY WHICH I OWN OR AM PURCHASING. SHOULD I BE REFERRED TO A FEDERAL OR STATE FUNDED MEDICAL ASSISTANCE PROGRAM I AUTHORIZE THE UVA MEDICAL CENTER TO RELEASE AND OBTAIN ALL INFORMATION NEEDED TO DETERMINE ELIGIBILITY FOR THAT FUNDING. I AGREE TO IMMEDIATELY NOTIFY UVA WHEN MY INSURANCE (MEDICAL OR PRESCRIPTION) AND/OR INCOME CHANGES.

SIGNATURE REQUIRED

APPLICANT’S SIGNATURE:

SPOUSE’S SIGNATURE:

DATE:

DATE:

This application was received by a UVa Medical Center Employee: _________________________________________________________________________________

Revised 10/11

FORM # 001FIN

(REV. 10/2011)

To reorder, log onto http://www.virginia.edu/uvaprint

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CONFIDENTIAL

UNIVERSITY OF VIRGINIA MEDICAL CENTER

APPLICATION FOR ASSISTANCE FORM INSTRUCTIONS

STEP 1: Complete patient information. Please fill out all information concerning the patient completely

STEP 2: Fill out income and asset information. This includes income from your employer, social service aid (Food Stamps, ADC, General Relief), government aid (social security, VA benefits) and all other income. If any child is 18 years or older, a separate form is required.

Who is head of household? This is the member of the family who provides food and shelter for the applicant. The applicant can also be the head of household. A non-family member should not be listed in the family member’s section.

IN ORDER FOR THE UNIVERSITY OF VIRGINIA MEDICAL CENTER TO COMPLY WITH STATE GUIDELINES, EACH OF THE ITEMS YOU HAVE LISTED ON THE FRONT OF THIS APPLICATION WILL REQUIRE PROOF OR DOCUMENTATION. PLEASE DO NOT SEND IN YOUR APPLICATION UNLESS YOU HAVE ATTACHED ALL DOCUMENTATION NEEDED. ALL INFORMATION MUST BE RETURNED AS SOON AS POSSIBLE OR YOU WILL BE RESPONSIBLE FOR YOUR CHARGES IN FULL.

THE FOLLOWING ARE TYPES OF DOCUMENTATION NEEDED.

PLEASE CHECK EACH ONE TO SEE WHICH ONES MAY APPLY TO YOUR SITUATION: (COPIES ONLY

PLEASE. ORIGINALS WILL NOT BE RETURNED.)

ÜPAY CHECK STUBS: If you are employed, you must provide 1 (one) month’s worth of your pay check stubs – not more than 3 months old. If your stubs are not available, you need to provide a letter from your employer stating 1 (one) month gross salary

ÜUNEMPLOYMENT: Forms verifying weekly benefit amount or denying unemployment or workers compensations

ÜOTHER RESOURCES: Copy of retirement benefits, General Relief check, ADC check, trust fund allotments, child support check and alimony

ÜGOVERNMENT BENEFITS: Letter confirming or denying Social Security, SSI, VA or other government benefits, photocopy of check (s) or bank statement showing automatic deposit.

ÜSEASONAL EMPLOYMENT: Please provide UVA Income Verification Form.

ÜSELF – EMPLOYMENT: Provide your current year Federal Income Tax return.

ÜLETTER OF SUPPORT: Letter verifying support from family or friends (when no income is reported or not enough to show support.)

ÜSOCIAL SERVICES: Approval, denial or pending status from your local department of social services. Any letters confirming receipt of housing and/or food stamps monthly benefit amount.

ÜBANK STATEMENTS: Most recent savings and/or checking account statement (s) from the bank or credit union.

ÜSICK LEAVE: Statement from doctor stating dated you are unable to work. Statement from employer indicating paid sick leave or if you are on leave without pay, year-to-date gross income, and hire date.

ÜSTUDENTS: Scholarships, loan, work-study, stipend, tuition, assistantship and grant award amounts.

ÜINVESTMENTS: Stocks, bonds, IRA’s 401k plan, CDs, securities – statement from bank/broker showing current value.

ÜPERSONAL PROPERTY: Tax statement showing assessed value of vehicle(s), and other items claimed with the amounts owed.

ÜREAL ESTATE PROPERTY: Most current tax statement showing acreage and value along with the mortgage statement from the bank.

ÜLIFE INSURANCE: Policy or statement specifying cash-in value if over $1,500.00

ÜOTHER: A copy of custody papers.

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Get Uva Financial Assistance PDF Form

Form Characteristics

Fact Name Details
Application Requirement All questions on the Uva Financial Assistance form must be answered completely.
Mailing Address Completed forms should be mailed to: Verification Department, Box 800750, Charlottesville, VA 22908-0750.
Documentation Necessity Applicants are required to attach proof of income and assets with the application.
Insurance Inquiry The form asks whether applicants have insurance that covers prescription medications.
Income Sources Income must include employment wages, social security, and other forms of assistance.
Legal Compliance This form adheres to applicable state laws governing financial assistance applications.
Signatures Both the applicant and their spouse, if applicable, must sign the declaration section.

Guidelines on Utilizing Uva Financial Assistance

Completing the UVA Financial Assistance form is an important step to ensure that you have access to the financial support you may need. Once you fill out the form and submit it with the necessary documentation, the verification department will review it and determine if you qualify for assistance. Follow these steps carefully to provide all required information accurately.

  1. Start with your patient information. Fill in the patient's name, Social Security number (this is required), address, birth date, city, state, and ZIP code. Include the medical record number and both home and work telephone numbers.
  2. Select the marital status by circling the appropriate option: Single, Married, Divorced, Separated, or Widowed.
  3. Move on to the income and asset information. List all family members, including yourself, spouse, and any children under 18. Provide details including their sex, Social Security number, birth date, relation to the patient, and monthly gross wages or other income sources.
  4. Document your employment details. For each family member listed, include their employer's name and phone number.
  5. Indicate if you have any insurance that covers prescription medications. If yes, list the name of the insurance provider along with the member IDs and group numbers.
  6. For any member who is unemployed, state when they last worked and whether they've applied for unemployment benefits. If applicable, clarify if they have applied for disability benefits.
  7. Determine if anyone in your household receives financial support like child support or alimony. If so, provide the amounts.
  8. Fill out the information regarding bank accounts. Include checking and savings account numbers, bank names, and balances. Include details about your stocks, bonds, or retirement accounts and their balances as well.
  9. Address any real estate property ownership. Specify if you own or are buying property, include the address, total acreage, and mortgage amount.
  10. If you have life insurance, provide the company’s name, policy number, and cash-in value of the policy.
  11. List any personal property such as vehicles. Include make, model, year, amount owed, and value for each item.
  12. Finalize the form by signing in the declaration section to confirm that the information is complete and accurate. Sign for yourself and your spouse if applicable, along with the date of signature.

After filling out the form, make sure to double-check all the information for accuracy. It's advisable to gather all necessary documentation that proves the details provided. This documentation is essential to support your application and help expedite the review process. Once everything is ready, mail your completed form to the address provided above to the verification department. Don't forget to keep a copy for your records!

What You Should Know About This Form

What should I include when filling out the UVA Financial Assistance Form?

When completing the UVA Financial Assistance Form, it is essential to provide all requested information clearly and accurately. This includes your personal details such as your name, social security number, birth date, and contact information. Additionally, you must detail the income and assets of all household members. If anyone receives child support, alimony, or has bank accounts, this information should also be included. Be sure to document your income sources such as pay stubs or benefit letters. If you need more space, you can attach a separate sheet with the relevant details.

How do I submit the completed UVA Financial Assistance Form?

Your completed form must be mailed to the UVA Medical Center’s Verification Department. The address is: Box 800750, Charlottesville, VA 22908-0750. Make sure to send the form as soon as possible to avoid any delays in processing your application. If you have questions about the mailing process, you can contact the verification department at 1-866-320-9659 for assistance.

What kind of documentation do I need to attach to my application?

Supporting documentation is crucial for the review of your application. You will need to provide proof of income, such as recent pay stubs or benefit verification letters from government agencies. Other required documents may include bank statements, proof of property ownership, or documentation of government benefits. Be sure to check which types of documents apply to your situation and provide only copies, as original documents will not be returned.

What happens after I submit my application?

Once you submit your application, the UVA Medical Center will review the information and documentation provided to determine your eligibility for financial assistance. If additional information is needed, a representative may contact you. It is important to respond promptly to any inquiries to avoid delays in processing your application. If approved, the assistance will help offset medical costs as specified in the program guidelines.

Common mistakes

Many applicants make common mistakes when filling out the UVA Financial Assistance form, which can delay the processing of their application or lead to denial. One common mistake is failing to provide complete information. Every question in the form must be answered. Neglecting to fill in any section, even minor details like a phone number or medical record number, can cause setbacks. It's important to double-check that all fields are completed before submission.

Another frequent error is not including necessary documentation. The form clearly states that certain proof is required for each item listed. Applicants often forget to attach pay stubs, bank statements, or proof of any other resources. Without these documents, your application may be deemed incomplete, preventing it from moving forward in the review process. It is critical to have all necessary documentation ready and attached to avoid delays.

Many people also overlook the importance of accurate income reporting. Applicants may misstate their monthly wages or fail to report additional sources of income, such as child support or alimony. Misrepresenting income can lead to a denial of financial assistance. It is essential to be completely honest and thorough when reporting any and all forms of income.

Lastly, failing to update changes in financial circumstances can jeopardize the application. If there are changes to income, insurance, or household composition, these must be reported immediately. Ignoring this responsibility can result in issues with eligibility for assistance and may require reapplication or additional documentation. Staying proactive about any changes ensures a smoother process.

Documents used along the form

The Uva Financial Assistance form is an essential document for individuals seeking financial support for medical services. To ensure a complete application, several accompanying documents may be necessary for verification of financial status. Below is a list of forms and documents that are commonly used alongside the Uva Financial Assistance form.

  • Pay Check Stubs: If employed, provide one month’s worth of paycheck stubs. This documentation should not be older than three months. If stubs are unavailable, a letter from the employer confirming salary may be required.
  • Unemployment Verification: Submit forms that verify the weekly benefit amount received or documentation regarding the denial of unemployment or workers' compensation claims.
  • Other Income Sources: Include copies of documents related to retirement benefits, General Relief, ADC checks, child support, or alimony payments.
  • Government Benefits: A letter verifying or denying eligibility for Social Security, SSI, VA benefits, or similar programs should be provided. Photocopies of relevant checks or bank statements are also acceptable.
  • Seasonal Employment Documentation: For those engaged in seasonal work, the UVA Income Verification Form is needed.
  • Federal Income Tax Return: Self-employed individuals must submit their current year’s Federal Income Tax return as evidence of earnings.
  • Letter of Support: A letter from family or friends outlining their support can be included if no income is reported, or if reported income is insufficient.
  • Bank Statements: The most recent savings and checking account statements should be attached to provide a financial overview.
  • Real Estate Documents: The most current property tax statements detailing acreage, value, and mortgage statements should accompany the application if applicable.

Providing accurate and comprehensive documentation will help in the timely processing of your financial assistance application. Ensure all copies are clear and legible to avoid delays in determination of eligibility.

Similar forms

  • Medicaid Application: Like the UVA Financial Assistance form, the Medicaid application collects detailed personal and financial information to determine eligibility for government-sponsored healthcare programs. Both forms require the applicant's income, asset details, and information on dependents to assess financial need.
  • Food Assistance Application (SNAP): This application is similar because it seeks to evaluate family income and expenditures to establish eligibility for food benefits. Both forms demand personal information and detailed financial disclosures, helping determine access to essential resources.
  • Public Assistance Application: This document serves to determine eligibility for various forms of public aid. It parallels the UVA Financial Assistance form in that it requires comprehensive financial data, information about family members, and documentation of expenses to evaluate support needs.
  • Housing Assistance Application: Like the UVA form, this application helps determine eligibility for housing programs by gathering information about income, assets, family size, and expenses. Both require proof of income and details about any real estate owned.
  • Unemployment Benefits Application: This document is similar as it collects detailed personal and financial data to assess eligibility for unemployment benefits. Applicants must disclose income sources and employment history, much like the UVA Financial Assistance form does.
  • Financial Aid Application (FAFSA): The Free Application for Federal Student Aid collects information about students’ financial situations. Both forms aim to ascertain financial need through comprehensive financial information, allowing applicants access to needed support services.
  • Disability Assistance Form: Similar to the UVA Financial Assistance form, this document collects personal and financial data to assess eligibility for disability-related benefits. Both forms require applicants to provide detailed information regarding their financial situation to determine support.

Dos and Don'ts

When filling out the Uva Financial Assistance form, it is important to approach the process carefully. Here are nine essential tips to ensure your application is complete and accurate.

  • DO read all instructions thoroughly before starting the application. Understanding the requirements will help you avoid common mistakes.
  • DO provide all requested personal information, including social security numbers and contact details. Incomplete information could delay the process.
  • DO ensure that you submit proof of income and assets with your application. Documentation is necessary for the review of your financial situation.
  • DO include income from all sources, such as wages, social security, and child support. This information is critical for determining your eligibility.
  • DO double-check all entries for accuracy before submission. Simple errors can lead to significant complications.
  • DON'T skip any questions or sections. Every piece of information is vital to your application.
  • DON'T submit original documents. Always provide copies, as originals will not be returned.
  • DON'T forget to sign and date the application. An unsigned form can be considered invalid.
  • DON'T delay in sending your application. Timeliness is key, as delays might lead to responsibility for charges.

Following these guidelines can greatly enhance your chances of receiving the financial assistance you need. Stay organized and proactive to ensure a smoother application process.

Misconceptions

Misunderstandings about the UVA Financial Assistance form can lead to confusion and delays. Here are five common misconceptions clarified:

  • Everyone qualifies for financial assistance. Many believe that simply applying guarantees assistance. However, eligibility is based on specific financial criteria and documentation must be provided to assess this accurately.
  • Only low-income families can apply. It’s a common assumption that financial assistance is available only to those with very low income. In reality, the form can assist individuals and families who face medical expenses that their income cannot cover, even if they aren't considered low-income on paper.
  • You don’t need to provide documentation if you’re unemployed. Some individuals think that if they are unemployed, they can skip the documentation process. In fact, proof of income, even zero income or unemployment claims, is still required to evaluate the application effectively.
  • Your assets don’t matter. Many applicants believe that only income is considered. This is incorrect; the form requires a full account of assets, including savings accounts, property, and personal belongings, which are crucial for determining financial need.
  • The application is only for medical bills. Another misconception is that the assistance applies solely to medical expenses. Actually, financial assistance can also cover costs related to medications and other healthcare services as well, making a broader range of financial support available.

Understanding these misconceptions can lead to a smoother application process and better outcomes for those seeking assistance.

Key takeaways

Filling out the Uva Financial Assistance form can seem daunting, but it's important for potential financial aid. Keep these key takeaways in mind:

  • Answer All Questions: Every question on the form must be answered to ensure your application will be processed.
  • Provide Accurate Income Information: Include detailed information about your income, including wages, benefits, and any other financial sources.
  • Attach Required Documentation: Submit proof of income, such as pay stubs, bank statements, and government aid letters. Incomplete applications can delay your assistance.
  • Be Thorough with Assets: Include all relevant assets, like savings accounts and property, to give a full picture of your financial situation.
  • Include Family Members: Make sure to list yourself, your spouse, and any children under 18. Accurate representation of household income is crucial.
  • Understand the Declaration: Sign the declaration at the end of the form to authorize the release of your information for eligibility verification.
  • Check Your Contact Information: Ensure your phone numbers and address are current so the verification department can reach you easily.
  • Keep Copies of Everything: Retain copies of the completed form and all supporting documents for your records.

Being organized and thorough when completing the Uva Financial Assistance form will enhance your chances of receiving the aid you need.

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