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Financial Assistance - Proof of Income

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To qualify for the CHRISTUS Health uninsured discount, a patient must fill out a financial assistance application and provide proof of total family household income within 30 days of discarge. Proof of total family household income and a completed financial assistance application are also necessary for those patients aiming to qualify for a Charity Care discount.

This proof of income must include either one of the following:

• Year-to-date gross earnings statement from employer
• Four to six of your most current pay stubs from employer
• W-2 earnings statement
• Previous calendar year income tax return
• Social security statement of earnings or Supplemental security income -SSI (Ask the Social Security Administration to release this information to us by filling out this Form 3288 release)
• Unemployment compensation determination letters
• Worker's compensation
• Retirement benefits/pension
• Veterans' benefit statement

Or two of the following:

• Written wage and earnings letter on employer letterhead
• Credit card report card
• Salary estimator
• Statement of self-employment earnings
• Food stamp benefits information
• Court documentation of bankrupt condition
• Other documents of sources of income
• Oral confirmation from employer
• Oral confirmation of use of homeless shelter, church, etc.
• Other oral confirmation of situation

Or all of the following:

• Credit report card
• Patient residence in area of high pverty
• Oral confirmation of use of homeless shelter, church, etc.

 

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