FAP English Application and Instructions

Financial Assistance Program Application Instructions

Guarantor Account: Date:

Dear Applicant:

Thank you for allowing us to be of assistance to you. Attached is an application for the Financial Assistance Program offered by Renown Health. The purpose of the Financial Assistance Program is to provide financial relief to guarantors who do not qualify for Federal, State, or County assistance, and have no reasonable means to meet their financial obligations for necessary medical services. The documents requested are used solely to determine eligibility for the Financial Assistance Program. If you have not already applied directly for Federal, State or County assistance we can help you with a simple screening to determine your potential eligibility. Please contact our Financial Assistance Specialist for help in applying by calling 775-982-4110.

Financial Assistance Requirements:

✓ All items on the application must be completed in full.

✓ A co-payment of $_ to be determined based on prescreen is required at the time you submit your application. Payment will be applied to any outstanding balances regardless of application approval

✓ Proof of Income( attach copies): o Recent month of Pay Stubs and / or other Source of Income( social security, unemployment, child support, alimony, etc.). o Last month’ s Bank Statements( include linked accounts, all pages). o Last month’ s / quarter’ s statement from any Other Asset Accounts( i. e., insurance policies, investments, life insurance distribution, legal settlement funds, etc.). o Prior Year Filed Tax Forms( 1040 forms and corresponding schedules).

✓

You must have proof of application and denial for assistance through your county’ s Social Services and State Welfare programs or of being excess income to apply

✓ A Trans Union Credit Report will be run to verify all information as presented on the application for Financial Assistance funds

. After all supporting documentation has been submitted, you will be notified in writing or by phone of the final determination of your eligibility. Please update us if your address or phone numbers change. If you have any questions regarding the Financial Assistance Program or need help completing the application form, please contact a Financial Assistance Specialist at Renown Health by calling 775-982-5747.

Renown Health 10315 Professional Circle T-6 Attn: Medical Financial Hardship Reno NV 89521 FAP @ renown. org

Form Number: 100-169 Revision Date: 4 / 2023