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The form also gathers household member income sources and includes a financial support letter section for support providers, plus patient or guardian certification and submission instructions including mailing, fax, or MyChart upload.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/hcap-trinity-health-application-form-complete-and-sign-within-10-days/563478/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/hcap-trinity-health-application-form-complete-and-sign-within-10-days/563478.png","ImageObject",442,249,{"name":88,"@type":89},"Sarah ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-19","2026-10-12",true,{"@type":98,"interactionType":99,"userInteractionCount":73},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What documents must be submitted with the HCAP application within the 10-day deadline?","Question",{"text":108,"@type":109},"The form requires completion and signature within 10 days, along with copies of required verifications such as proof of gross income, bank statements, and tax returns or profit and loss statements. Additional documents may be required depending on the applicant’s situation.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What patient details are requested in the application?",{"text":113,"@type":109},"The application asks for patient name, date of birth, Social Security/EIN (optional), contact information, mailing address, state of residency, marital status, dates of hospital service, federal tax return status, dependent eligibility, health insurance coverage at the time of service, and U.S. residency status.",{"name":115,"@type":106,"acceptedAnswer":116},"Who should complete the Letter of Financial Support and what does it confirm?",{"text":117,"@type":109},"Only the support provider should complete the letter. It verifies whether the provider contributes more than 50% of the patient’s living expenses while being unable to help with medical bills, and includes a confirmation that the provider will not be held liable for the patient’s bills.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},563478,1792403887,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":73,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},962085320529,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","| Please complete and sign application form and return within 10 days including copies of the following: |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Required Verifications\u003Cbr>☐ Past One month Proof of Gross Income ☐ Past Three months Proof of Gross Income (if applying for HCAP)\u003Cbr>☐ Past Two months Complete Bank Statements for all bank accounts, with all pages included ( Explanation for recurring deposits)\u003Cbr>☐ Recent Tax Returns (1040 form with Schedule C, E or F) or Three Months Profit and Loss Statements (for selfemployed/dependents)\u003Cbr>Provide the following, If applicable\u003Cbr>☐ Recent W2 for Seasonal Income ☐ Unemployment Benefit/ Denial letter ☐ Child Support Income /Alimony ☐ No Income – Complete Letter of Financial Support portion of the application |  |  |  |  |  |  |  |\n| Patient Information |  |  |  |  |  |  |  |\n| Patient Name |  |  |  |  |  | Date of Birth |  |\n| Social Security/EIN Number (optional) |  |  |  | Mobile Phone |  | Other Phone |  |\n| Mailing Address |  |  |  | City |  | State | Zip code |\n| Email Address |  |  |  | What state are you a resident of? |  |  |  |\n| Marital status Single □ Married □ Divorced □ Other □   |  |  |  |  |  |  |  |\n| Date (s) of Hospital service: From   To   |  |  |  |  |  |  |  |\n| Do you file a Federal Tax Return? □ Yes □ No If no, why? |  |  |  | Can you be claimed as dependent on someone else's tax return? □ Yes □ No |  |  |  |\n| Did you or your dependents have health insurance coverage at the time of service? □ Yes □ No (Provide Insurance card copy) |  |  |  |  |  |  |  |\n| Are you a documented resident of the United States? □ Yes □ No □ Prefer Not to Answer |  |  |  |  |  |  |  |\n| Household Members, including yourself based on your recent Tax Returns | Date of Birth | Relationship to Patient | Income for 3 months prior to hospital service |  | Income for 12 months prior to hospital service |  | Claimed on Tax Return (Y/N) |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n\n\n|  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Income Verification for all household members |  |  |  |  |  |  |\n| Monthly Income Source | Who receives this? | Gross Monthly Income (before taxes) | Monthly Income Source |  | Who receives this? | Gross Monthly Income (before taxes) |\n| Wages |  |  | Worker’s\u003Cbr>Compensation |  |  |  |\n| Social Security / Disability |  |  | Unemployment |  |  |  |\n| Pension |  |  | Child Support/Alimony |  |  |  |\n| Self-Employment |  |  | Rental Land Income |  |  |  |\n| Public Assistance |  |  | Other |  |  |  |\n| Letter of Financial Support-Should only be completed by support provider |  |  |  |  |  |  |\n| ☐ I provide more than 50% support for the patient's living expenses, but I am unable to help with medical bills.☐ By signing this letter, I verify that the above statement is correct and that I will in no way be held liable for the patient's bills. If you have questions, please contact me at   (Phone Number) |  |  |  |  |  |  |\n| Name of person supporting |  |  |  | Relationship to Patient |  |  |\n| Signature of person providing support |  |  |  | Date |  |  |\n\nVerification of Income and Identification  \nI certify that the information listed in this application is true and complete to the best of my knowledge. I understand that the information provided is subject to verification. I will be responsible for repayment of any services provided at Trinity Health affiliates if the above information is provided under false pretenses.  \nSignature of Patient:   Date:    \nOr Signature of Legal Guardian:   Date:  (If Applicable)  \nRelationship to Patient:   Date:    \nPlease mail your application tothe address above, Fax at 312-871-3350 and or upload documents through MyChart (Patient Portal) -[https://mychart.trinity-health.org/MyChart](https://mychart.trinity-health.org/MyChart) If you have any questions, please contact our Customer Service Center at 800-494-5797 Monday t","cbCais0GZtWE6vBr","https://ap.wps.com/l/cbCais0GZtWE6vBr","pdf",115034,"English","# Required Verifications\n# Patient Information\n## Household Members and Income\n# Income Verification for All Household Members\n# Letter of Financial Support\n# Verification and Submission","[{\"question\":\"What documents must be submitted with the HCAP application within the 10-day deadline?\",\"answer\":\"The form requires completion and signature within 10 days, along with copies of required verifications such as proof of gross income, bank statements, and tax returns or profit and loss statements. Additional documents may be required depending on the applicant’s situation.\"},{\"question\":\"What patient details are requested in the application?\",\"answer\":\"The application asks for patient name, date of birth, Social Security/EIN (optional), contact information, mailing address, state of residency, marital status, dates of hospital service, federal tax return status, dependent eligibility, health insurance coverage at the time of service, and U.S. residency status.\"},{\"question\":\"Who should complete the Letter of Financial Support and what does it confirm?\",\"answer\":\"Only the support provider should complete the letter. It verifies whether the provider contributes more than 50% of the patient’s living expenses while being unable to help with medical bills, and includes a confirmation that the provider will not be held liable for the patient’s bills.\"}]","HCAP Trinity Health Application Form - Complete and Sign within 10 Days | PDF",1791835902]