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Page 1 of 12 Form FA-APP01 (02/24/2020)
Financial Counseling: Phone: 501-537-8641
Email: [email protected]
CARTI Toll-Free: 1-855-552-2784
MRN:Patient Name:Date of Birth:
Patient Financial Assistance Application
Para asistencia en español, por favor solicite un
intérprete.
Completion of this application will allow CARTI to review your
eligibility for receiving assistance from the Patient Financial
Assistance / Charity Care program. It is important that you
complete this application and return it with all required
documentation within ten (10) business days. If you have difficulty
completing this application or you have additional questions,
please contact a CARTI Financial Counselor. Submission of a
completed application and required documentation does not guarantee
approval for financial assistance, and you remain responsible for
your account balance. Please complete all sections and submit all
required documents. We may request additional documents if
necessary to review and validate your application.
Patient Information
Patient’s Name:
Telephone Number: Date of Birth:
Sex: Arkansas Driver’s License Number / State ID Number:
Male Female
Social Security Number:
Primary Residence Address Line 1:
Address Line 2:
City: State: Zip Code
Home Phone Number: Mobile Phone Number:
Marital Status: Marital Status Year:
Single Married Widowed Divorced Separated
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Page 2 of 12 Form FA-APP01 (02/24/2020)
Authorized Representative
Authorized Representative / Guardian
Same as Patient Completed by Representative/Guardian Denoted
Below
Authorized Representative Name:
Telephone Number: Date of Birth:
Sex: Arkansas Driver’s License Number / State ID Number:
Male Female
Social Security Number:
Primary Residence Address Line 1:
Address Line 2:
City: State: Zip Code
Home Phone Number: Mobile Phone Number:
Marital Status: Marital Status Year:
Single Married Widowed Divorced Separated
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Page 3 of 12 Form FA-APP01 (02/24/2020)
Household Income Sources
List All Household Members:
Full Legal Name Date of Birth Employer / School Relationship
Patient Spouse Dependent Responsible Party Patient Spouse Dependent
Responsible Party Patient Spouse Dependent Responsible Party
Patient Spouse Dependent Responsible Party Patient Spouse Dependent
Responsible Party
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Page 4 of 12 Form FA-APP01 (02/24/2020)
Household Income Financial Breakdown
List Combined GROSS (Pre-Tax/Pre-Deductions) ANNUALIZED (YEARLY)
Income for each Member of the Household Category:
Income Source Patient Spouse Dependents Resp. Parties Gross
Salary / Wages Self-Employment Rental Self-Employment / Contract
Dividends / Interest Stocks / Bonds / Investment Distributions
Trust Distributions Public Assistance Social Security Unemployment
Workers’ Compensation Alimony Annuity Distributions Child Support
Military Family Allotments Retirement / IRA / Pension Strike
Benefits Disability Food Stamps Insurance Distributions (i.e.
Life)Lottery / Gambling Winnings Other: Other: Other:
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Page 5 of 12 Form FA-APP01 (02/24/2020)
Household Expenses
List Combined ANNUALIZED (YEARLY) Expenses for each Member of
the Household Category:
Expense Source Patient Spouse Dependents Resp. Parties
Vision/Dental Medication Out of Pocket Child/Elderly Care Primary
Residence Rent / Mortgage Other Loans Payments Property Taxes
Utilities - Telephone Utilities - Electricity Utilities - Gas
Utilities - Water Food Clothes Car Payment / Transportation Credit
Cards Health Insurance Premiums Life Insurance Premiums Other
Insurance Premiums Other: Other: Other:
Non-CARTI Outstanding Medical Bill Balances:
Source / Facility Current Balance Medical Service Owner Patient
Spouse Dependent Responsible Party Patient Spouse Dependent
Responsible Party Patient Spouse Dependent Responsible Party
Patient Spouse Dependent Responsible Party
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Page 6 of 12 Form FA-APP01 (02/24/2020)
Household Assets - Vehicles
List Vehicles for Household:
Year Make Model Purchase Price Owner Patient Spouse Dependent
Responsible Party Patient Spouse Dependent Responsible Party
Patient Spouse Dependent Responsible Party Patient Spouse Dependent
Responsible Party
Household Assets – Depository & Cash Bearing Accounts
List Bank / Depository / Investment Accounts for Household.
Include any cash on-hand or reserves over $500 held (such as in a
deposit box or safe).
Bank / Depository Name Current Balance Owner Patient Spouse
Dependent Responsible Party Patient Spouse Dependent Responsible
Party Patient Spouse Dependent Responsible Party Patient Spouse
Dependent Responsible Party Patient Spouse Dependent Responsible
Party
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Page 7 of 12 Form FA-APP01 (02/24/2020)
Household Assets - Property
List Property Assets for Household (Home, Trailer, Land, Boat,
Camper, Non-Primary Residence):
Property Description Purchase Price Purchase Year Owner Patient
Spouse Dependent Responsible Party Patient Spouse Dependent
Responsible Party Patient Spouse Dependent Responsible Party
Patient Spouse Dependent Responsible Party Patient Spouse Dependent
Responsible Party
Hardships
Please check all conditions that apply and for which you can
substantiate the appropriate documentation:
You are currently homeless or were homeless within the past six
(6) months. You were evicted or facing eviction or foreclosure
within the past six (6) months. You received a shut-off notice from
a utility company within the past one (1) month. You experienced
domestic violence within the past one (1) year. You experienced the
death of a family member within the past six (6) months. You
experienced a fire, flood, or other natural or human-caused
disaster that caused substantial damage to your primary residence
within the past one (1) year. You filed for bankruptcy within the
past six (6) months. You experienced unexpected increases in
necessary expenses due to caring for an ill, disabled, or aging
family member within the past six (6) months. You claim a child as
a tax dependent who’s been denied coverage for Medicaid and CHIP
within the past one (1) year.
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Page 8 of 12 Form FA-APP01 (02/24/2020)
Questionnaire
Latest Tax Returns Filed: Latest Federal Adjusted Gross Income
(AGI):
Federal State
Latest Arkansas Medicaid Application Decision Date:
Arkansas Medicaid Application Decision:
Did not Apply / Refuse to Apply Approved, Full Approved, QMB
Approved, SMB Approved, Spend-Down Approved, Other:
____________________________________ Denied Due Incomplete
Application / Missing Documentation Denied Due to Income Denied Due
to Assets Denied Due to Look-Back Penalty / Disqualifying Transfers
Denied, Other: ______________________________________
Marketplace Insurance Application Decision:
Did not Apply / Refuse to Apply Approved & Enrolled
Approved, but Could not Afford Denied, Reason:
____________________________________
PRIMARY HEALTH INSURANCE POLICY
Company / Carrier Name: Member ID:
Policy Name / Type: Group ID:
SECONDARY HEALTH INSURANCE POLICY
Company / Carrier Name: Member ID:
Policy Name / Type: Group ID:
SUPPLEMENTAL COVERAGE (Health Ministry, Cancer Policy, Etc)
Company / Carrier Name: Member ID:
Policy Name / Type: Group ID:
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Page 9 of 12 Form FA-APP01 (02/24/2020)
CERTIFICATION
I UNDERSTAND THAT THIS APPLICATION MAY NOT BE PROCESSED UNTIL
ALL REQUIRED INFORMATION IS SUBMITTED. I UNDERSTAND THAT ADDITIONAL
INFORMATION MAY BE REQUIRED TO PROCESS MY APPLICATION.
I AFFIRM THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE
BEST OF MY KNOWLEDGE. I AUTHORIZE CARTI TO OBTAIN A COPY OF MY
CREDIT REPORT IF DEEMED NECESSARY TO AID IN DETERMINING MY
ELIGIBILITY FOR FINANCIAL ASSISTANCE. I ALSO HEREBY AUTHORIZE CARTI
THE RIGHTS TO CONTACT ANY OF THE ABOVE LISTED EMPLOYERS, CREDITORS,
BANKS, OR LISTED THIRD PARTIES FOR THE PURPOSE OF CONFIRMING MY
INCOME, ASSETS, EXPENSES, AND FINANCIAL STATUS. I UNDERSTAND THAT I
WILL BE DISQUALIFIED FROM APPLYING FOR CARTI FINANCIAL ASSISTANCE
IN THE FUTURE IF ANY OF THE INFORMATION ON THIS APPLICATION OR ON
ACCOMPANYING SUBMITTED DOCUMENTATION IS FOUND TO BE MATERIALLY
FALSE, FABRICATED, ALTERED, OR A MISREPRESENTATION OF THE
TRUTH.
FUTHERMORE, I AGREE TO NOTIFY CARTI OF ANY CHANGE IN MY
INSURANCE AND ELIGIBILITY STATUS IF APPROVED FOR FINANCIAL
ASSISTANCE.
Patient or Authorized Legal Representative Signature
Print Patient or Authorized Legal Representative Name
Relationship to Patient
Date
Application Information - Completed by Financial Counselor
ONLY
Medical Record Number:
Application Submission Date:
Financial Counselor Name:
Application Review Date:
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Page 10 of 12 Form FA-APP01 (02/24/2020)
Patient Financial Assistance Documents Checklist
Government Medical Assistance Determination
One (1) or more document required, dated within 6 months of
Application Submission Date:
Arkansas Medicaid Determination Letter Marketplace Determination
Letter Medicare Determination Letter Other Government Healthcare
Coverage/Assistance Determination Letter
Proof of Insurance Coverage
One (1) or more document required per Healthcare Insurance or
Policy denoted on the application:
Health Savings Account or Flexible Spending Account Statement
Marketplace Coverage Determination Letter(s) Supplementary (Health
Ministry, Cancer Policy, etc) Coverage Policy Letter(s) Medical
Insurance Card(s) or Policy Coverage Letter(s) from Company
Income
Two (2) or more document required per Member of Household and/or
Responsible Party, dated within 12 months of Application Submission
Date:
Most Recent Federal Income Tax Return(s) and/or State Income Tax
Return(s) Most Recent W-2s and 1099s Last 6 Pay Statement(s) from
All Employers Social Security and Supplemental Security Income
Statements or Award Letter(s) Unemployment Statement(s) Workers
Compensation Statement(s) or Award Letter(s) Rental / Farm /
Business Income Document(s) Retirement Income Statement(s) (i.e.
IRA, Pension, 401lk, 403b, etc)
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Page 11 of 12 Form FA-APP01 (02/24/2020)
Assets
First Item Listed Below AND One (1) or more document required
per Listed Asset, dated within 12 months of Application Submission
Date:
(Always Required) Account Summary Statement(s) from All Bank,
Investment, and Other Depository Accounts Listed with Last 3 months
of Transactions Present
Account Statement(s) from All Loan Accounts with Last 3 Months
of Transactions Present Investment / Security Account Statement(s)
Retirement Account Statement(s) Trust Account Statement(s) Mortgage
Statement(s) for non-primary residence(s)
Expenses
Two (2) or more document required:
Medical Bills Received within Last 3 Months Credit Card
Statement(s) or Summary Document(s) Bills for Rent, Electric, Gas,
Telephone, or Water Received within Last 3 Months Bills from Other
Living Expenses to Patient Received within Last 3 Months
Residency
One (1) or more document required:
Mortgage Statement(s) State / County Tax Bill(s) Utility Bill(s)
Rent / Lease Agreement(s) or Statement(s) Deed / Title
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Page 12 of 12 Form FA-APP01 (02/24/2020)
Identity
One (1) or more document required for the Patient and/or
Authorized Representative:
Driver’s License or State ID (Not Expired) Social Security Card
Birth Certificate Passports or Passport Card(s) U.S. Citizenship
Identification Card(s)
Department of Homeland Security & U.S. Citizenship &
Immigration Services Issued Forms, such as Permanent
Resident/Resident Alien Card, Certificate of Naturalization,
Certificate of Citizenship, Employment Authorization
Marriage Certificate Military ID Armed Forces Discharge
Papers
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