Charity Care Income Criteria and Required Information

(Revised September 2021)

Patients are required to submit at least one (1) document from each of the four (4) categories listed below:

1. Valid Identification

  • Driver’s License – Valid (unexpired)
  • State/County ID
  • Social Security card
  • Birth Certificate
  • If homeless with none of the above forms of identification, an attestation form should be completed

2. Proof of New Jersey Residency for Date(s) of Service

  • Utility bill for date of service
  • Valid (unexpired) driver’s license with current address
  • Support letter (if not working and living with someone)
  • If homeless with none of the above forms of residency, an attestation form should be completed

3. Income Information

  • If employed, must present one of the following:
    • Weekly income – Four (4) most recent pay stubs
    • Bi-weekly income – Two (2) most recent pay stubs
    • Letter from employer on company letterhead (to include the beginning date of employment, hourly wage, and number of hours worked weekly)
  • Self-employed – profit and loss statement
  • Disability income (Social Security awards letter must be presented advising of the monthly amount received)
  • Social Security – Provide the most current letter from Social Security advising monthly amount received
  • Worker’s comp – Provide the pay stubs or a letter from the fund. The letter must include the date worker’s comp began, hourly rate, and weekly hours worked, based on gross income.
  • If unemployed – Unemployment statements. If receiving a direct deposit, a patient will need to obtain proof directly from Unemployment by calling 609.292.2460.
  • Pension payments – Present most current letter from pension stating how much received and how often
  • Insurance or annuity payments – Present most current letter from insurance or fund stating how much received and how often
  • Plan G income for that month/public assistance
  • Alimony/Child support
  • Rental income from rental property
  • Dividends
  • Monetary support (receiving financial support from friends or family)
  • Letter of support if not working and living with someone
  • Homeless not working/no income — an attestation can be completed with a financial representative.

4. Asset Information as of the Date of Service

  • Bank statement for checking and savings account
  • Life insurance policy value
  • 401(k)
  • Stocks/Bonds
  • R.A
  • CD
  • T-Bills
  • No bank accounts – attestation will be filled out by a financial representative.
  • Homeless with no assets — an attestation can be filled out with a financial representative.

Required Information for Different Groups

Patients That Are Married

  • Spouses are held to the same four (4) documentation requirements as the patient.
  • A spouse must sign all attestations applicable to them. Download the Patient Attestation form
  • If separated, a patient must present spouse ID, income, and assets. If there are no financial ties, then the patient will need to complete an attestation supplied by the Medical Center.

Patients with Children

  • ID (Social Security card or birth certificate) is required for each minor child under 18 (if the patient has custody or minor child/children).

Support Letters – Must Present One of the Following

Pre-Printed Letter

  • Download the Statement of Support Assistance form.
  • We strongly recommend that pre-print support letters be filled out by the person providing support. The supporter must then sign and give a contact phone number. The supporter must also provide a valid form of proof of address, as is noted in #2 above.

Handwritten Letters 

  • Must be dated with the date of admission
  • A complete address with zip code
  • The relation of the patient to the supporter. The length of residency at the address.
  • The supporter must attest that the patient does not have any income, assets, job, or bank accounts and that free room and board are being provided to them.
  • The supporter must then sign and give a contact phone number.

Patients eligible for less than 100% Charity Care are required to pay a deposit before admission. (Patients not eligible for 100% charity care may be eligible for a Compassionate Billing Discount.)

Payments methods accepted are cash, check, money order, Visa, MasterCard, and American Express.

Questions?

Please get in touch with our Financial Assistance Department at 201.967.4114 or 201.967.4200.

Visit the New Jersey Hospital Care Payment Assistance Program.

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