Financial Assistance Application-Employee v2

Financial Assistance Application

For CHEMED Employees ONLY

Click here to view our sliding fee schedule

Do you live in New Jersey?*

YesNo

Application Date*

MonthDayYear
Date
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Email
example@example.com
Gross Annual Income (total of all family members)*
Household Size*
PLEASE LIST ALL HOUSEHOLD/FAMILY MEMBERS.

PLEASE USE THE ADD FAMILY OPTION BELOW
Instructions on who to include in your household

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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 Members - list all dependents including yourself*
Is anyone in your household pregnant?*

YesNo
Expected due date

MonthDayYear
Date
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 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
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*

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

YesNo
Effective Date*

MonthDayYear
Date
I certify that the family size and income information shown above is correct.
What are you applying for? Select all that apply*

NJ Family Care / Emergency Medicaid (Presumptive Eligibility)Sliding Scale Financial Assistance
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
Staff Signature

Clear

BLANK
DONT USE Family Size*
Should be Empty: