I have read Mountain View Charity's eligibility requirements for patients. (Found on the Medical Financial Assistance Page) *

Please Check Box

Date (if applicable): *

Provider Information

Providers Name/Practice: *

Office Contact: *

Phone Number: *

E-mail: *

Initial Eligibility Survey

Mountain View Charity prefers to fund insurance premiums and/or deductibles as a way to guarantee continued access to care.

Uninsured patients are required to seek health insurance coverage. If coverage is obtained, applicant needs to provide proof of insurance. If patient is denied insurance, applicant needs to provide a letter of insurance coverage denial. Funding will not occur until this step is met.

Please assist your patients in accessing Your Health Idaho to determine if they are eligible for insurance.

Does this patient have a new diagnosis? *

Yes. This patient might be eligible
No. Mountain View Charity only offers help to get a patient immediate access to care. This charity does not fund past services or chronic conditions.

Has this healthcare provider evaluated our patient's financial situation? *

Yes, this patient cannot meet their financial obligations and faces significant obstacles to getting care.
No. Please evaluate their financial need before applying

Is this patient insured? *

Yes
No, but this patient is in the process of applying for coverage.

Patient Information

Patient Name: *

Date of Birth: *

Phone Number: *

E-mail: *

Is patient employed? *

Please briefly explain what you know about this patient's immediate financial needs and resources: *

What is the patient's diagnosis?: *

Date of initial diagnosis: *

Briefly explain patient's current health care needs: *

Cost of medical procedures? (Estimate): *

Does patient currently have medical insurance (Including Medicare/Medicaid Pay)? *

Amount applying for? (Funds requested can only be applied to patient’s out-of-pocket costs) : *

How will the funds be used? (Please be Specific)? *

If applying for prescription medication, please list medications/dosages/instructions below :

Date money is needed by: *

Has your office offered at least a matching reduction in fees? *

Please explain what financial assistance your office is willing to offer this patient: *

Check(s) will be made out to: *

If applying for mulitple payees, please provide additional contact information. :

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Financial Assistance Application

Provider Information

Initial Eligibility Survey

Patient Information