Catalpa Cares Application

Client Name*

First Last

Date of Birth*

Account Number*

Service Line:*

Please complete the following application and return to Catalpa Health. To ensure fair and proper use of donated funds, we request financial information to determine and document the need for this support.

Does the client qualify for Medical Assistance?*

Yes

Please provide Medical Assistance number*

Has the client been approved for financial assistance through Ascension or ThedaCare?*

Yes

Please provide a copy of the approval with this application.*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 150 MB.

The reason I am requesting financial assistance is: (please check appropriate box)*

I cannot afford my co-pay.

I cannot afford deductible.

I have exceeded the maximum annual insurance benefit.

Other

Adjusted Gross Income on 1040 (Line 11):*

Household Size:*

The information I have provided is true and accurate. I understand that Catalpa will bill my insurance. I further understand that it is my responsibility to notify Catalpa of insurance or financial changes.

Guarantor Name*

First Last

Guarantor Signature*

Comments

This field is for validation purposes and should be left unchanged.

Catalpa Health is a 501(c)(3) supported by three hospital systems and our community

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