Major Services Financial Assistance Application | Norton Healthcare Louisville, Ky.

Major Services Financial Assistance Application

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.
  • 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

  • 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.

  • 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.
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