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The form determines eligibility to pay bills when a patient is uninsured, insurance is exhausted, or paid medical expenses exceed 10% of income. It collects personal, contact, income, insurance status, and responsible-party information, includes certification and authorization for verification, and outlines minimum eligibility guidelines such as application timing, pending-account protections, appeal rights, and limits on collection actions.",{"@graph":63,"@context":122},[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/nys-uniform-hospital-financial-assistance-application-hospital-financial-assistance-form/568722/",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/nys-uniform-hospital-financial-assistance-application-hospital-financial-assistance-form/568722.png","ImageObject",442,249,{"name":88,"@type":89},"Mia  ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-16","2026-10-13",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114,118],{"name":105,"@type":106,"acceptedAnswer":107},"Who may qualify for NYS hospital financial assistance under this application?","Question",{"text":108,"@type":109},"Patients may be eligible if they are uninsured, if insurance is exhausted, or if they have insurance and can show paid medical expenses totaling more than 10% of their income.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information does the application collect from the patient or responsible party?",{"text":113,"@type":109},"It gathers patient identification and contact details, mailing address, birth date, parent/guardian information when applicable, income details, health insurance status, and responsible-party authorization if someone else signs.",{"name":115,"@type":106,"acceptedAnswer":116},"When can the applicant apply, and what rights apply while the application is pending?",{"text":117,"@type":109},"Applicants can apply at any point during the collection process. 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Completing  \nthis form will start your request for hospital financial assistance. This form is used by all hospitals in New York State Personal & Confidential  \nGuarantor:  \nCase Number:  \nPatients Included in Case:  \nDear  \nThank you for selecting St. Joseph’s Health as your health care provider. Please complete the enclosed application and return to the address below to complete the evaluation of your financial assistance.  \nIf you have any questions, please contact our Customer Service Center at 800-494-5797, Monday through Friday between 9:00 a. m. -5:00 p. m. ET.  \nSincerely,  \nTrinity Health Enterprise Patient Financial Services On behalf of St. Joseph’s Health  \n20555 Victor Parkway Livonia, MI 48152  \nNYS Uniform Hospital Financial Assistance Application  \nFor Hospital and Professional services provided by facilities and physicians of Trinity Health  \nYou may be eligible for hospital financial assistance to pay your bills if you are uninsured, if your insurance is exhausted, or if you have health insurance but have proof of paid medical expenses totaling more than 10% of your income. Completing this form will start your request for hospital financial assistance. This form is used by all hospitals in New York State  \n\n| Patient Name (complete information that is applicable) |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Patient Name (First, Middle, Last) |  |  |  | Date of Birth (mm/dd/yyyy) |\n| Contact Phone \\# |  |  |  |  |\n| Mailing Address |  | Apartment/ Unit \\# |  |  |\n| City |  | State |  | Zip code |\n| Parent/Guardian or Lawful Representative Name (if patient is a minor child or an incapacitated adult) |  |  |  |  |\n| Email Address |  |  |  |  |\n| Full Name | Relationship |  | Total Gross Income (Current) |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n| The hospital may request you submit documentation as proof of income, examples of documentation might include a pay stub, a letter from your employer if applicable, or Form 1040. |  |  |  |  |\n\nNYS Uniform Hospital Financial Assistance Application  \nFor Hospital and Professional services provided by facilities and physicians of Trinity Health  \nYou may be eligible for hospital financial assistance to pay your bills if you are uninsured, if your insurance is exhausted, or if you have health insurance but have proof of paid medical expenses totaling more than 10% of your income. Completing this form will start your request for hospital financial assistance. This form is used by all hospitals in New York State  \n\n| Health Insurance Status\u003Cbr>Do you have any form of health insurance, including Medicaid, Medicare, or private insurance through your employer or purchased on your own? □ Yes □ No\u003Cbr>If you answered “No” would you like assistance in applying for any of these programs? □ Yes □ No\u003Cbr>Underinsured patients: people with insurance and high medical expenses. If you have insurance, please provide an estimate of the medical bills you paid in the past 12 months. |  |  |  |\n| --- | --- | --- | --- |\n|  | $ |  |  |\n| The hospital may request you submit documentation as proof of paid medical expenses. |  |  |  |\n| Patient/Responsible Party: If not the patient, list the name of the person signing the form and their authority to sign on behalf of the patient (e.g., spouse, parent, legal representative) . |  |  |  |\n| I understand that the information I submit may be subject to verification from external sources. I certify that the information is true and complete to the best of my knowledge. | ","cbCaih06eWxHQ7Zq","https://ap.wps.com/l/cbCaih06eWxHQ7Zq","pdf",168007,7,"English","# Guarantor and Patient Case Information\n## Application Instructions and Customer Support\n## Patient and Contact Details\n## Health Insurance Status\n## Certification, Signature, and Mailing/Fax/Upload\n## Minimum Eligibility and Guidelines\n## Application Timeline, Patient Rights, and Confidentiality","[{\"question\":\"Who may qualify for NYS hospital financial assistance under this application?\",\"answer\":\"Patients may be eligible if they are uninsured, if insurance is exhausted, or if they have insurance and can show paid medical expenses totaling more than 10% of their income.\"},{\"question\":\"What information does the application collect from the patient or responsible party?\",\"answer\":\"It gathers patient identification and contact details, mailing address, birth date, parent/guardian information when applicable, income details, health insurance status, and responsible-party authorization if someone else signs.\"},{\"question\":\"When can the applicant apply, and what rights apply while the application is pending?\",\"answer\":\"Applicants can apply at any point during the collection process. The hospital cannot forward accounts to collection while the application is pending, and the applicant does not have to make payment before a decision is issued.\"},{\"question\":\"What should be done if the applicant is denied financial assistance?\",\"answer\":\"The applicant has the right to appeal, and the information on how to appeal is provided in the hospital’s notice and decision letter.\"}]","NYS Uniform Hospital Financial Assistance Application - Hospital Financial Assistance Form | PDF",1791872091]