We have updated our Online Services Terms of Use and Privacy Policy. See our Cookies Notice for information concerning our use of cookies and similar technologies. By using this website or clicking “I ACCEPT”, you consent to our Online Services Terms of Use.

HCAP Request Application Form

Please complete all information requested on this form to begin the HCAP process. As you continue, we will request additional information to assist with determining HCAP eligibility. Please provide the name, age, relation and income for the 3 and 12 months prior to the “patient’s date of service” on ALL family members under the age of 18 living in the home with the patient. If you have any questions, please contact the Hospital Billing Customer Service Department. Thank you.

Please, complete all fields marked with an asterisk (*), as they are required.

Contact Information
I'm not a robot