Dear Patient,
Thank you for choosing Wilmington Health Ambulatory Surgery Center (“WH ASC”) to meet your health care needs. Our financial assistance program relieves the financial burden of medically necessary health care and is available to patients and families with a household income at or below 250% of the Federal Poverty Guideline for your family size.
To determine your eligibility, please complete the application form and provide all required supporting documents. You can upload the documents at the end of this form or submit by secure fax to 910-523-5031. Failure to return a complete application with all supporting documents will delay your application decision and normal billing procedures will continue.
Required Documents
| Income and Assets | Proof of most recent 30 days gross income and assets for the patient, spouse or guarantor, and all household dependents 18 years of age and older as listed on the income page of the application.Household gross income and assets includes but are not limited to pay wages, self-employment, social security, Veterans benefits, pension, investments, retirement, unemployment, workers’ compensation, alimony, disability, rental properties, and bank accounts.If you do not have any income, please include a letter of support, signed and dated, from the person who provides you with assistance. |
| Tax Return | A copy of the most recent year Federal Tax Return – Form 1040 including all schedules. If you do not have a copy of your taxes call the IRS at 1-800-829-1040 for a free transcript. |
| Bank Accounts | Most recent month traditional and/or alternative bank account statements for checking, savings, money market, investment, and/or retirement accounts. Must be in bank statement format showing beginning balance, transactions, and ending balance. Include all pages of the statement with the last four digits of the account number visible. |
| Property | Tax value of owned property other than your primary residence. If other property is a rental property, provide proof of rental income such as a lease agreement or receipt. |
| Other | If no taxes filed provide birth certificates or custodian documents for all minor dependents, marriage certificate if married, death certificate if patient is deceased. |
*Do NOT send original documents.*
If you are eligible for NC Medicaid or other State or Federal programs, you must apply and continue to pursue all benefits. To complete the required screening for Medicaid, contact your local Department of Social Services.