MEDICAL

GROUP

Enclosed you will find a Financial Hardship Application and Required Information Form.
In order to apply for Sentara Medical Groups discount, the attached application must be
completely filled out and signed. The Required Information Form lists the documents
that are required as proof of your income. In order to be considered for this discount, we
must receive your signed and completed application with the required documents within
30 days. Your application will not be processed if it is incomplete. You may submit
your completed application to your physicians office or mail it to:
Sentara Medical Group
Attention: Charity Dept.
P.O. Box 179
Norfolk, VA 23501-0179
A representative will contact you once we have received and processed your application.
Should you not qualify for this discount, a payment plan may be an alternative.
Please note this application is for Sentara Medical Group only. If you have completed a
recent charity application through another medical facility, i.e. hospital, Health Dept, etc.,
you may forward a copy of that application to us for review; a signature and copy of your
ID is still required. Outside charity applications vary with different organizations, so you
may be contacted if additional information is required. Please make sure your contact
information is correct on your application to avoid any unnecessary delay in processing
your application.
If you have any questions please feel free to contact us toll free at 757-983-9000 or
1-888-236-2263. Our office hours are Monday through Friday 8:00a.m.to 4:30p.m.
Please allow 10 days after submitting your completed application to verify status. Thank
you for your prompt attention.
Sincerely,

Sentara Medical Group

Charity Department

SENTARA MEDICAL GROUP

REQUIRED INFORMATION FOR CONSIDERATION OF FINANCIAL HARDSHIP
DISCOUNT

_____________________________________________________________________________

In order to process your application, proof of income is required. If your request is for
services prior to the current year, proof of income for that specific year is required. A list
of acceptable documentation is listed below. A signature and identification card must be
submitted along with your completed application in order to process.

VALID DRIVERS LICENSE OR IDENTIFICATION CARD

MOST RECENT IRS TAX FORMS (1040 AND/OR W-2) (MUST BE SIGNED)
CHECK STUBS FOR THE PAST 30 DAYS FOR ALL QUALIFYING PERSONS EMPLOYED IN
THE HOME
PROOF OF ALL OTHER INCOME RECEIVED IN THE PAST 30 DAYS
MOST RECENT BANK STATEMENT
AWARD OR DENIAL LETTER FROM SOCIAL SECURITY/DISABILITY
UNEMPLOYMENT LETTER / UNEMPLOYMENT CHECK STUBS FOR THE PAST 30 DAYS
MEDICAID CARD, IF APPLICABLE

WE WILL BE UNABLE TO PROCESS YOUR REQUEST WITHOUT YOUR SIGNATURE, A

PICTURE IDENTIFICATION CARD, PROOF OF INCOME, OR AN INCOMPLETE
APPLICATION.

SHOULD YOU HAVE ANY QUESTIONS ABOUT THE APPLICATION OR REQUIRED

DOCUMENTS, PLEASE CALL OUR CUSTOMER SERVICE DEPARTMENT TOLL FREE @
(757) 983-9000 OR (888) 236-2263.
PLEASE RETURN ALL ITEMS (AS APPLICABLE) ON THIS CHECKLIST ALONG WITH YOUR
COMPLETED APPLICATION TO THE ADDRESS LISTED BELOW:

SENTARA MEDICAL GROUP

ATTENTION: CHARITY DEPT.
P.O. BOX 179
NORFOLK, VA 23501-0179

Sentara Medical Group

Charity Care Application

Eligibility Determination

Patient Name(s):_________________________________________________________________
Patient Address: _________________________________________________________________
Phone #
(home):______________________________________(cell):______________________________
Account(s)#_____________________________________________________________________
Application Requested by: ______________________ Relationship to Patient: _______________
List every member of the patients household, including patient, as listed on the tax return. Use additional sheets if necessary.

NAME

AGE

RELATIONSHIP

GROSS MONTHLY
INCOME

Total number in household? ____ Do you own your home? ___Yes ___No

EMPLOYER NAME,
ADDRESS AND PHONE

Do you rent? ___ Yes ___ No

Gross Amount per Month

All Other Sources of Income

(Public Assistance, Unemployment, Workers Comp., etc.)

____________________________________
____________________________________
____________________________________

___________________________
___________________________
___________________________

Check any of the following Medical Resources that you have:

___ Commercial Insurance
___ Medicaid

___ Veterans
___ Champus /Tricare
___ Medicare
___ Vocational Rehabilitation ___ State and Local Hospital ___ Public Health Service

What is the Current Balance? ___________

Was this service due to an accident in which you may have a claim or be represented by an attorney? ___________
If yes, what is the attorneys name and contact information? _____________________________________________
Should you have any questions about this application, please contact our Central Billing Office @ 757-983-9000 or toll
free @ 888-236-2263.
I certify that the above information is true and correct. I authorize Sentara Medical Group to verify this information with employers
and other agencies. I also understand that this information is subject to review by Federal and/or State agencies. I also understand
that I am expected to make application to any other help which may be available to me.
Signature ___________________________

Date Requested _________________________

TO BE COMPLETED BY MANAGER
Date received_______________ By_________________ Documents for income verification__________________
Approved for Charity

Denied

Date Charity Care _______________________

Reason:_____________________________________________
Determination Pending _______________________________