Major Services Financial Assistance Application

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At Norton Healthcare, financial assistance for hospital-based charges is available to anyone who meets the eligibility requirements for total gross income, total resources, and then furnishes documentation to confirm this information. Financial assistance is provided for hospital-based charges at any of the following locations:

Norton Audubon Hospital
Norton Brownsboro Hospital
Norton Hospital
Norton Women’s and Children’s Hospital
Norton Children’s Hospital
Norton Children’s Medical Center

Norton Cancer Institute
Norton Cardiovascular Center – Springs
Norton Cardiovascular Center – Dixie
Norton Diagnostic Center – Dupont
Norton Diagnostic Center – Fern Creek
Creek Norton Diagnostic Center – St. Matthews

Please fill out the information below and once a determination is made, you will receive a response from our Financial Assistance Department. Please provide all the information requested so that we may accurately assess your need for assistance.

Note: The information you provide is encrypted and submitted securely. It is only used for the purpose of qualification for financial assistance. Please read our privacy policy to learn more.

* Asterisk indicates a required field.

Account Number*
Patient Name*
First Last
Date of birth*
SSN*
Address*
Street Address Address Line 2 City State ZIP Code
Home phone*
Mobile phone
Email*
Is patient a U.S. citizen?
- Yes
- No
Is patient a legal U.S. resident?
- Yes
- No
Patient's employer (if minor, parent's info)
Employer phone*
Spouse's employer
Employer phone
If You Have Health Insurance, Please Provide
Company name
Company phone
Policy #
Policy holder name
First Last
Was this stay due to a car accident?
- Yes
- No
Accident date
Attorney information
Is account related to Workers Compensation?
- Yes
- No
Injury date
Attorney information
List the Name, Age and Relationship of Members in Household to the Patient:
Household member 1 name
Household Member 1 Date of Birth
Household member 1 relationship to patient
Household member 2 name
Household member 2 Date of Birth
Household member 2 relationship to patient
Household member 3 name
Household member 3 Date of Birth
Household member 3 relationship to patient
Household member 4 name
Household member 4 Date of Birth
Household member 4 relationship to patient
Household member 5 name
Household member 5 Date of Birth
Household member 5 relationship to patient
Gross Income (Monthly)
Patient's income (If patient is a minor, Mom's monthly income)*
Spouse's income (If patient is a minor, Dad's monthly income)*
If you have no income, who pays for your expenses?
Other Gross Income (Monthly)
K-TAP
Social Security
SSI / Disability
Unemployment
Food Stamps
Pension
Other income
TOTAL MONTHLY INCOME*
Expenses (Monthly)
Rent / Mortgage
Telephone
Food and Supplies
Utilities
Other Expenses
Total monthly expenses*
Countable Resources
Checking account bank name
Checking account value
Savings account bank name
Savings account value
Money market bank name
Money market value
Mutual fund bank name
Mutual fund value
401(k) name
401(k) value
403(b) name
403(b) value
Bonds bank name
Bonds value
IRA bank name
IRA value
Other resources
Other resources value
Total resources*
Property
Home mortgagee
Current home value
Current home equity
Other property mortgagee
Other property current value
Other property current equity
Other homes mortgagee
Other homes value
Other homes equity
Auto #1 year/make/model
Auto #1 current value
Auto #1 current equity
Auto #2 year/make/model
Auto #2 current value
Auto #2 current equity
Other autos? Please provide year, make, model, owner, current value and current equity
Other properties? Please provide year, make, current value and current equity
ATV, MOTORCYCLE, MOTORHOME, ETC.
THIS CERTIFIES THAT I REQUEST TO BE CONSIDERED FOR FINANCIAL ASSISTANCE AT NORTON HEALTHCARE.

I HEREBY AGREE to furnish Norton Healthcare with the information necessary to determine my eligibility for assistance with the medical bills resulting from the services I have received at their facilities. I understand that my physicians and other health care providers may have financial assistance policies that could assist me with the medical bills from those providers. As such, I authorize Norton Healthcare to provide a copy of my application to those providers who request it to assist them in determining whether I qualify for benefits under their financial assistance programs.

I certify that the information provided by me in this application is correct and true to the best of my knowledge and belief. I understand that if I give false information or withhold information in applying for assistance, my application will be denied and Norton Healthcare will continue to pursue collection of any outstanding balance due. In that instance, I may also be subject to prosecution for fraud.

I agree to notify Norton Healthcare of any changes to the information provided in this form including address, telephone number, and income.
Consent*
By checking here I certify that I have read and understand the above paragraphs, and that I request to be considered for financial assistance for hospital charges at Norton Healthcare.
- Yes
Responsible party name*
CAPTCHA
Date*

Norton Healthcare
Customer Service

(502) 479-6300

Or toll-free

(800) 874-3979

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Major Services Financial Assistance Application

Major Services Financial Assistance Application

If You Have Health Insurance, Please Provide

List the Name, Age and Relationship of Members in Household to the Patient:

Gross Income (Monthly)

Other Gross Income (Monthly)

Expenses (Monthly)

Countable Resources

Property

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