Financial Assistance Application

Financial Assistance Application
Are you an employee of CHEMED?*

YesNo
If you are an employee of CHEMED and would like to register for financial assistance, you must apply with the following link. Employee Application

Are you a resident of New Jersey?*

YesNo
Application Date*

MonthDayYear
Date
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Email
example@example.com
Family Size*
Gross Annual Income (total of all family members)*
Do you have ID?

YesNo
Please upload ID

Cancelof
You have 7 days to submit proof of ID. If not received within 7 days, you will be responsible for the full billed amount.
Please upload proof of residence

Cancelof
Do you have proof of income?*

YesNo
File Upload

Cancelof
I attest that my income is correct as indicated above - Please initial*
I/we certify that this information is complete and accurate. *

Clear
I am interested in applying for the sliding fee scale, however my application is incomplete at this time. My payment may not cover the cost of my visit. I understand that if the application has not been completed at the time of my appointment, I will be charged $160.

In order to determine the cost of today’s visit, I must complete my Slide application with a Financial Assistance representative at the CHEMED Financial Assistance office by bringing the following documents within 7 days, no later than the date below -
- ID - Adults ID or passports, childrens birth certificate or social security card.
- Proof of residence - most recent utility bill, rent lease, bank statement or car insurance card.
- Proof of Income - last 4 pay stubs, most recent tax return, employer letter.
Do you have an appointment at CHEMED*

YesNo
Date of your appointment *

MonthDayYear
Date
The following section requires patients' demographic and income information. Please read all sections carefully and fill in the information accurately.
DONT USE Applicant (patient) Name

First NameLast Name
DONT USE Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DONT USE Phone Number
Please enter a valid phone number.
DONT USE Email
example@example.com
Citizenship*

US CitizenGreen Card HolderNon US Citizen
How many years do you have your green card? *
Date of entry*

MonthDayYear
Date
Do you have Medicaid in another state?*

YesNo
Marital Status*

SingleSeparatedWidowedMarriedDivorced
Race*

WhiteHispanicAfrican AmericanOther
Household Size*
Household Members - list all dependents including yourself*
Household Income - list all members receiving income.*
Do you or any household members receive any other source of income?*

YesNo
Enter income amount:*
How often paid*

WeeklyMonthlyAnnuallyBi-weeklySemi-monthly
Total annual household income*
Monthly family income
Is anyone in your household pregnant?*

YesNo
Expected due date

MonthDayYear
Date
Do you have any of the following? please select all that apply*

Private InsuranceNJ Family CareTravelers InsuranceMedicaidMedicareNone of the above
Does it cover dental?*

YesNo
Effective Date*

MonthDayYear
Date
In the following section you will be asked to uplaod supporting documents. Please upload documents for each member of the household.
Proof of ID - one of the following - valid drivers license, valid passport, birth certificate, social security card or green card.

Cancelof
Proof of income - one of the following - last 4 paystubs, most recent tax return or employer letter. If currently in school or unemployed - school letter.

Cancelof
Proof of residence - one of the following - most recent utility bill, rent lease, bank statement or car insurance card.

Cancelof
I certify that the family size and income information shown above is correct. Copies of ID for every family member, tax returns, pay stubs and other information verifying income, and proof of residency are required before a discount is approved. I understand that based on the above information, I may not be eligible for financial assistance. I understand that I may be required to follow up to qualify for financial assistance. If I am not eligible for financial assistance, I understand that I will be held responsible for the balance on my account(s Please note that direct costs, such as IUD’s and pharmaceuticals may not be covered under the sliding fee.

I acknowledge that I was informed of the documents that need to be returned in order to complete my application. I understand that if i fail to complete the slide application within 7 days, I will become financially responsible for the full, unreduced cost of today's visit.
Signature of patient/guardian*

Clear
Date*

MonthDayYear
Date
Complete application by:

MonthDayYear
Date
Staff Signature

Clear
Should be Empty: