OFFICE HOURS: (732) 499-6169 - HOURS: 8:30 AM - 4:30 PM
NO APPOINTMENT REQUIRED
ROBERT WOOD JOHNSON HOSPITAL RAHWAY
865 STONE ST
RAHWAY, NJ 07065
Fax (732) 499-6132
THE REQUESTED INFORMATION BELOW MUST BE PROVIDED AT THE TIME OF YOUR INTERVIEW WITH A FINANCIAL COUNSELOR.
***ADDITIONAL INFORMATION MAY BE REQUESTED AFTER THE APPLICATION IS REVIEWED.***
***PLEASE NOTE THAT ANY AND ALL INFORMATION BEING PRINTED FROM THE INTERNET, MUST BE VERIFIED BY A SIGNATURE AND STAMP FROM THAT COMPANY.***
PROPER IDENTIFICATION (SUPPLY ONE OF THE FOLLOWIN FOR EACH FAMILY MEMBER)*** If you are a full time college student 21 yrs or
younger you must provide all documents for both parents as well. They will be included in your family size as well as any siblings who are full time student 21 yrs or younger ***
1. Driver's License
2. Social Security Card
3. Valid Passport
4. Birth Certificate
PROOF OF NEW JERSEY RESIDENCY: (FOR THE MONTH OF YOUR REQUESTED SERVICE). You must supply one of the below required documents.
1. Utility Bill
2. Copy of Lease or Deed
3. Driver's License
4. Letter from individual stating that you live with him/her
Actual gross income for the month immediately preceding the date of service or three month's income immediately preceding service:
- Pay stubs, unemployment stubs, disability, child support.
- A letter from employer(s) on company letterhead (INCLUDING Name, Address and Telephone number) - Letter must state the Gross Income, also needs to state if covered by health insurance.
- Copy of social security and/or pension award letter.
- If not employed and have no income, must supply a letter from person supporting you.
- If you receive financial aid for schooling you must supply the financial aid award letter for your last 2 semesters immediately preceding your date of service.
You must provide copies of any checking and savings accounts, IRA's, CD's, stocks and/or bonds, or any other account which can be readily
converted into cash. All account statements must be valid for the date of service in question.
If you are under the age of 18, over the age of 65, Blind or Disabled or pregnant - You must show proof that you were screened for eligible
COPY OF ALL PAGES YOU COMPLETED TAXES AND W2 FOR THE PRIOR YEAR
COPIES OF ANY AND ALL INSURANCES CARDS FOR EACH FAMILY MEMBER
New Jersey Hospital Care Assistant Program
APPLICATION FOR PARTICIPATION
PROOF OF IDENTIFICATION, PROOF OF INCOME AND PROOF OF ASSETS MUST ACCOMPANY THIS APPLICATION
SEND COPIES OF ALL REQUESTED DOCUMENTS; DO NOT SEND ORIGINAL DOCUMENTS AS THEY WILL NOT BE RETURNED
APPLICATION FOR FINANCIAL ASSISTANCE
PROVIDER NAME: Robert Wood Johnson University Hospital
SECTION III - Income Criteria
When determining eligibility for hospital care assistance, a spouse's income and assets must be used for an audit; parent's(s) income
and assets must be used for a minor child. Proof of income must accompany this application.
Income is based on the calculation of either twelve months, three months or one month of income prior to the date of service.
Patient/Family Gross Income equals the lesser of the following:
16. SOURCES OF INCOME:
Social Security Benefits
Unemployment & Workmen's Compensation
Other Monetary Support
Insurance or Annuity Payments
Net Business Income (self employed/ verified by independent source)
Other (strike benefits, training stipends, military family allotment, income from estates and trusts)
SECTION IV - Certification by Applicant
I understand that the infomation which I submist is subject to verification by the appropriate health care facility and the Federal or State Governments.
Willful misrepresentation of these facts will make me liable for all hospital charges and subject to civil penalties.
If so requested by the health care facility, I will apply for the governmental or private medical assistance for payment of the hospital bill.
I certify that the above information regarding my family size, income and assets is true and correct.
I understand that it is my responsibility to advise the hospital of any change in status in regards to my income or assets.
17. SIGNATURE OF PATIENT OR GUARANTOR