Form DMHAS-7097 "Application for Financial Assistance" - Ohio

What Is Form DMHAS-7097?

This is a legal form that was released by the Ohio Department of Mental Health and Addiction Services - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2014;
  • The latest edition provided by the Ohio Department of Mental Health and Addiction Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DMHAS-7097 by clicking the link below or browse more documents and templates provided by the Ohio Department of Mental Health and Addiction Services.

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Download Form DMHAS-7097 "Application for Financial Assistance" - Ohio

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OHIO DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES
Print AFA
APPLICATION FOR FINANCIAL ASSISTANCE
Attempts
1st Name/Date
2nd Name/Date
3rd Name/Date
Patient Name
Admission Date
PCS Number
Hospital
Patient's Marital Status
SSN
Date of Birth
If Divorced when final
Single
Widower
Separated
Divorced
Married
Address
City
State Zip
Phone#
Name of the Patient’s Spouse
Spouse’s Social Security# Spouse’s Date of Birth
Is Spouse's address different than Patient's?
Yes
No
Address
City
State Zip
Phone#
If “Yes”, Patient's VA Claim Number
Patient's Military Service Serial Number
Is the patient a veteran:
Yes
No
GUARDIAN
Guardianship Number
Name of Guardian
Does the patient have a court appointed guardian?
Yes
No
Type of Guardian:
Person
Estate
Both
Address
City
State Zip
Phone#
INSURANCE (Hospitalization)
Yes
No
- Private Policies, Employer Group and Union Group Health Insurance.
Policy covering patient issued in the name of:
Relationship of the Insured to the patient: Member ID:
Group Number:
Claim Phone#
SUBSCRIBER INFORMATION:
DOB
SSN
Address (Street, City, State Zip)
Phone#
Name(s) and Address(es) of Insurance Company(ies):
MEDICARE
Yes
No
Important - Please indicate in applicable space below patient's name and health insurance claim number exactly
MEDICAID
as indicated on patient's Medicare and Medicaid Card(s)?
Yes
No
Medicare Account Number
Medicare Part A Date of Entitlement
Medicare Part B Date of Entitlement
ID Number on Patient’s Medicaid Card
Medicaid (if applicable) Date of Entitlement
Patient’s Name (exactly as shown on Medicaid Card)
DEPENDENTS -
Yes
No
Does patient have dependents -
List all patient's dependents. If patient has more than three dependents, please
attach a separate sheet with the additional information
Name
Custody
Date of Birth
Relationship
ADDITIONAL DEPENDENTS INFORMATION - Check any of the following for whom you may claim a deduction as an additional dependency.
Patient is legally blind or deaf
Spouse is legally blind or deaf
Yes
No
Yes
No
Patient is 65 years of age or older
Spouse is 65 years of age or older
Yes
No
Yes
No
DMHAS-7097 (Rev. 11/14)
Page 1 of 3
OHIO DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES
Print AFA
APPLICATION FOR FINANCIAL ASSISTANCE
Attempts
1st Name/Date
2nd Name/Date
3rd Name/Date
Patient Name
Admission Date
PCS Number
Hospital
Patient's Marital Status
SSN
Date of Birth
If Divorced when final
Single
Widower
Separated
Divorced
Married
Address
City
State Zip
Phone#
Name of the Patient’s Spouse
Spouse’s Social Security# Spouse’s Date of Birth
Is Spouse's address different than Patient's?
Yes
No
Address
City
State Zip
Phone#
If “Yes”, Patient's VA Claim Number
Patient's Military Service Serial Number
Is the patient a veteran:
Yes
No
GUARDIAN
Guardianship Number
Name of Guardian
Does the patient have a court appointed guardian?
Yes
No
Type of Guardian:
Person
Estate
Both
Address
City
State Zip
Phone#
INSURANCE (Hospitalization)
Yes
No
- Private Policies, Employer Group and Union Group Health Insurance.
Policy covering patient issued in the name of:
Relationship of the Insured to the patient: Member ID:
Group Number:
Claim Phone#
SUBSCRIBER INFORMATION:
DOB
SSN
Address (Street, City, State Zip)
Phone#
Name(s) and Address(es) of Insurance Company(ies):
MEDICARE
Yes
No
Important - Please indicate in applicable space below patient's name and health insurance claim number exactly
MEDICAID
as indicated on patient's Medicare and Medicaid Card(s)?
Yes
No
Medicare Account Number
Medicare Part A Date of Entitlement
Medicare Part B Date of Entitlement
ID Number on Patient’s Medicaid Card
Medicaid (if applicable) Date of Entitlement
Patient’s Name (exactly as shown on Medicaid Card)
DEPENDENTS -
Yes
No
Does patient have dependents -
List all patient's dependents. If patient has more than three dependents, please
attach a separate sheet with the additional information
Name
Custody
Date of Birth
Relationship
ADDITIONAL DEPENDENTS INFORMATION - Check any of the following for whom you may claim a deduction as an additional dependency.
Patient is legally blind or deaf
Spouse is legally blind or deaf
Yes
No
Yes
No
Patient is 65 years of age or older
Spouse is 65 years of age or older
Yes
No
Yes
No
DMHAS-7097 (Rev. 11/14)
Page 1 of 3
OHIO DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES
APPLICATION FOR FINANCIAL ASSISTANCE
EMPLOYMENT
Currently Working
Unemployed
If Unemployed, Final Date of Employment
Patient's Employment Status
Employer's Name
Employer's Address
City
State Zip
Phone#
Patient’s Occupation
Patient’s Adjusted Gross Income LastYear
Spouse's Employment Status
Currently Working
Unemployed
If Unemployed, Final Date of Employment
Spouse Employer's Name
Employer's Address
City
State Zip
Phone#
Spouse’s Occupation
Spouse’s Adjusted Gross Income LastYear
SOURCE OF OTHER INCOME
Does Patient have a Payee?
Below, please provide Payee's Name, Address and Telephone Number.
Yes
No
Monthly Amount
Source
Patient
Spouse
Total
SS
Payee:
SSI
Payee:
SSDI
Payee:
VA Pension
Unemployment
Alimony
Child Support
Other
Yes
No
Does the patient or spouse have any other income?
If Yes, explain and indicate amount of income below:
Other
Other
If income = 0, please explain how supported.
BANK ACCOUNT
Yes
No
List all of patient's or spouse's bank accounts owned individually, jointly, or in trust.
Does the Patient or Spouse have a banking account?
Name(s) on the account
Bank Name & Address (Street, City, State Zip)
Current Balance Type of Account
Yes
No
OTHER ASSETS
- Stocks, bonds, IRAs - if additional space is needed, please attach information.
Account Number
Name & Address (Street, City, State Zip) where account is held
Current Balance Type of Account
DMHAS-7097 (Rev. 11/14)
Page 2 of 3
OHIO DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES
APPLICATION FOR FINANCIAL ASSISTANCE
REAL ESTATE
Yes
No
List below any real estate owned individually or jointly by patient. If additional space is
Does the Patient or Spouse own real estate?
-
needed, please attach information.
Primary
Current Market
Current Mortgage
How Titled
Address (Street, City, State Zip)
Residence
Value
Balance
Yes
No
Yes
No
LIABILITIES
Yes
No
Does the Patient or Spouse have any liabilities?
-
List all of patient's or spouse's liabilities.
Items
Name & Address (Street, City, State Zip) where account is held
Monthly Amount
Mortgage
Home Insurance
Other
Other
EXPENSES
Yes
No
List all of patient's or spouse's expenses.
Does the Patient or Spouse have any expenses?
-
Items
Name & Address (Street, City, State Zip) where account is held
Monthly Amount
Gas
Electric
Phone
Other
Other
LIFE INSURANCE AND/OR PREPAID FUNERAL EXPENSES
Yes
No
Does the patient have life insurance?
- If “yes” complete the following:
Name and Address of Life Insurance Company:
Policy Number
Name and Address of Beneficiary:
Face Value of Insurance:
Yes
No
Does the patient have Prepaid Funeral Expenses?
- If “yes” complete the following:
Name and Address of Prepaid Funeral Home:
Amount Prepaid for Funeral:
Section 5121 of the Ohio Revised Code establishes the liability for the support of patients admitted to a state mental health facility and requires the Department of Mental
Health & Addiction Services to investigate the financial resources of all patients and liable relatives. Ohio Revised Code 5121.36 (B) states that in order to be considered, the
application for modification or waiver of payment must be submitted to the department no later than ninety (90) days after the date the patient is admitted to a hospital.
THE INFORMATION IS CERTIFIED AS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT IF THIS INFORMATION IS NOT COMPLETE OR ACCURATE, I
MAY BE CHARGED THE FULL RATE.
Signature of Patient, Spouse or Legal Guardian completing the form
Date Completed
Patient refused to sign:
___________, ___________, ___________
DMHAS-7097 (Rev. 11/14)
Page 3 of 3
OHIO DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES
APPLICATION FOR FINANCIAL ASSISTANCE
Return To:
Contact No:
Date:
DMHAS-7097 (Rev. 11/14)
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