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Genesis Healthcare, Inc.
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GHC Home
New Patient Application
Annual Patient
Sliding Fee Application
GHC Sliding Fee Application
General
Select GHC Location
Please select your GHC office
*
Pee Dee Health Care
Genesis Healthcare Darlington (Behavioral Health)
Olanta Family Care
Lamar Family Care
Walterboro Family Care & Pediatrics
Genesis Healthcare Florence
Lowcountry Pediatrics
Application
Proof of acceptable income includes but is not limited to your yearly income tax return (must be completed), copy of your last month’s paycheck stubs, current bank statement showing direct deposit. If you do not have the prior proof, you may sign the Patient Financial Self-Attestation Agreement.
First Name
*
*
Middle Name
*
Last Name
*
*
Address
*
City
*
State
*
Zip
*
Phone
*
*
Date of Birth
*
*
Have you applied for medical assistance?
Yes
No
Do you or any family member of your household receive Medicare Extra Help or any other type of low-income subsidy?
Yes
No
If no, would you like assistance in applying for any extra help?
Yes
No
Family Member
To Be Completed by Patient/Guardian for EACH family member of the household
1.
Name
*
DOB
*
Relationship
Self
Sibling
Spouse
Parent
Child
Other
Relationship Other
*
Income Verification Method
Check/Pay Stub
Bank Statement
W2 Form
Social Security Award Letter
No Income
Other
Income Verification Other
*
If you have multiple income verification methods to list or do not see your type of income verification method listed, please enter the information in this 'Other' field.
Income Frequency
Weekly
Bi-Weekly
Semi-Monthly
Monthly
IRS Form 1040
Income
*
*
Number only
GHC Patient?
Yes
No
Account Number
*
2.
Name
*
DOB
*
Relationship
Self
Sibling
Spouse
Parent
Child
Other
Relationship Other
*
Income Verification Method
Check/Pay Stub
Bank Statement
W2 Form
Social Security Award Letter
No Income
Other
Income Verification Other
*
If you have multiple income verification methods to list or do not see your type of income verification method listed, please enter the information in this 'Other' field.
Income Frequency
Weekly
Bi-Weekly
Semi-Monthly
Monthly
IRS Form 1040
Income
*
*
Number only
GHC Patient?
Yes
No
Account Number
*
3.
Name
*
DOB
*
Relationship
Self
Sibling
Spouse
Parent
Child
Other
Relationship Other
*
Income Verification Method
Check/Pay Stub
Bank Statement
W2 Form
Social Security Award Letter
No Income
Other
Income Verification Other
*
If you have multiple income verification methods to list or do not see your type of income verification method listed, please enter the information in this 'Other' field.
Income Frequency
Weekly
Bi-Weekly
Semi-Monthly
Monthly
IRS Form 1040
Income
*
*
Number only
GHC Patient?
Yes
No
Account Number
*
4.
Name
*
DOB
*
Relationship
Self
Sibling
Spouse
Parent
Child
Other
Relationship Other
*
Income Verification Method
Check/Pay Stub
Bank Statement
W2 Form
Social Security Award Letter
No Income
Other
Income Verification Other
*
If you have multiple income verification methods to list or do not see your type of income verification method listed, please enter the information in this 'Other' field.
Income Frequency
Weekly
Bi-Weekly
Semi-Monthly
Monthly
IRS Form 1040
Income
*
*
Number only
GHC Patient?
Yes
No
Account Number
*
5.
Name
*
DOB
*
Relationship
Self
Sibling
Spouse
Parent
Child
Other
Relationship Other
*
Income Verification Method
Check/Pay Stub
Bank Statement
W2 Form
Social Security Award Letter
No Income
Other
Income Verification Other
*
If you have multiple income verification methods to list or do not see your type of income verification method listed, please enter the information in this 'Other' field.
Income Frequency
Weekly
Bi-Weekly
Semi-Monthly
Monthly
IRS Form 1040
Income
*
*
Number only
GHC Patient?
Yes
No
Account Number
*
6.
Name
*
DOB
*
Relationship
Self
Sibling
Spouse
Parent
Child
Other
Relationship Other
*
Income Verification Method
Check/Pay Stub
Bank Statement
W2 Form
Social Security Award Letter
No Income
Other
Income Verification Other
*
If you have multiple income verification methods to list or do not see your type of income verification method listed, please enter the information in this 'Other' field.
Income Frequency
Weekly
Bi-Weekly
Semi-Monthly
Monthly
IRS Form 1040
Income
*
*
Number only
GHC Patient?
Yes
No
Account Number
*
7.
Name
*
DOB
*
Relationship
Self
Sibling
Spouse
Parent
Child
Other
Relationship Other
*
Income Verification Method
Check/Pay Stub
Bank Statement
W2 Form
Social Security Award Letter
No Income
Other
Income Verification Other
*
If you have multiple income verification methods to list or do not see your type of income verification method listed, please enter the information in this 'Other' field.
Income Frequency
Weekly
Bi-Weekly
Semi-Monthly
Monthly
IRS Form 1040
Income
*
*
Number only
GHC Patient?
Yes
No
Account Number
*
Total Annual Income:
Total Annual Income:
*
Self-Attestation
Patient Financial Self-Attestation Agreement/Acknowledgement
I understand that Genesis Healthcare, Inc. will use the information that I have provided to determine my financial eligibility for federally subsidized health care. I further attest that the information that I have provided to Genesis Healthcare, Inc. is true and correct. I understand it is my responsibility to notify GHC of any changes to my income. I also understand that I must re-apply for the sliding fee program every 12 months, or sooner if my family household income changes.
To Accept, please select 'Accept':
Accept
I acknowledge that I have been provided information related to this Application and DECLINE to participate at this time.
To Decline, please select 'Decline':
Decline
Reason for Decline (if applicable):
*
Print Name
*
*
Patient Financial Self-Attestation Agreement/Acknowledgement
Relationship to Patient
*
Patient Financial Self-Attestation Agreement/Acknowledgement
Signature
*
*
Patient Financial Self-Attestation Agreement/Acknowledgement
HHS Poverty Guidelines
HHS Poverty Guidelines
