Financial Assistance Application

Financial Assistance Application

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

Do you live in New Jersey?

Application Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Press "View" for instructions on who to include in your household
Include:
- Spouses / Legal Domestic partners.
- Children (biological or adopted) aged 21 or under who live at home or are away at school and are claimed as tax dependents.
- Father of a child in the household (including unborn).
Do not include:
- Other relatives living in the house (Grandparents, siblings, etc.).
- Unmarried partner with no shared children.
- Roommates, friends, and others who are not domestic partners.
- Children who file their own taxes.
Household Size
PLEASE LIST ALL HOUSEHOLD/FAMILY MEMBERS.

PLEASE USE THE ADD FAMILY OPTION BELOW
Household Members - list all dependents including yourself
Is anyone in your household pregnant?
Expected due date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If you do not submit the required documents today, CHEMED offers a one-time courtesy to use the sliding fee program. This courtesy may be used once per year, per family, for one visit only at CHEMED.

You must complete your financial assistance application for continued coverage. Please send ID for each family member, one proof of address, and one proof of income. Please see the list of acceptable documents below. Documents should be sent to FA@chemedhealth.org.
- 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
Failure to provide the necessary documentation will result in future appointments being billed at the full rate.
Gross Annual Income (total of all family members)
Do you have ID?
Please upload ID

Cancelof
Please submit proof of ID before your next visit.
Please upload Proof of Address

Cancelof
Do you have proof of income?
Please Upload Proof of Income

Cancelof
Household Income - list all members receiving income.
Do you have any of the following? please select all that apply
Does it cover dental?
Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I certify that the family size and income information shown above is correct.
What are you applying for? Select all that apply
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. 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, I will become financially responsible for the full, unreduced cost of the today/ future visits.
Signature of patient/guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ECW Account Number
Approving Staff Name
Staff Signature

BLANK
DONT USE Family Size
Should be Empty: