Patient Application for HCAP.
Please fill out the following information.
  So that your financial assistance claim can be properly handled, please answer all questions carefully and completely. All required information is indicated in Red with an asterisk (*).  
Kettering Medical Center Network Application for HCAP

  • Patient Information
  • First Name:*   
    Middle Initial:
    Last Name:*   
    Home Telephone Number: (ex. 937-555-1234)
    Social Security Number:* (ex. 123-45-6789)
    Birth Date:* (ex. 01/30/04)
  • Financial Information
  • Date of Service:
    Person Completing Application:*
    Patient Care Facility:*
    Have you applied for Medicaid benefits within the last 90 days?
    Will you be active recipient of Disability Assistance at the time of your hospital service?
    Will you have health insurance (other than Medicaid) at the time of your hospital service?
    Total number of eligible family members (including the patient) who live in the household:*
    Please list eligible family members names, ages, and relationships below.
    (Foster children and step-children are not eligible)*
    Family Member Name Age Relationship
    Reported income must be for time periods prior to date(s) of hospital service.
    Total gross family income for the previous 3 months $:*
    Total gross family income for the previous 12 months $:*
    If you reported $0 income, provide a brief explanation of how you are living: