Dear Patient,

Thank you for choosing UNC Health to meet your health care needs. UNC Health is proud of its long history of providing health
care services to all North Carolinians. 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 who are North Carolina residents.

To determine your eligibility, please complete the enclosed application and provide all required supporting documents. Return
the application and the supporting documents in the envelope provided, upload through My UNC Chart at
https://myuncchart.org, or submit by secure fax to (984) 974 – 6454. Failure to return a complete application with all
supporting documents will delay your application decision and normal billing procedures will continue.

Required Documents
NC Residency 2 proofs of North Carolina residency listed on the NC Residency Requirements page of the application.

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 or call our office at
(984) 974-3425 or toll-free at (866) 704-5286.

For questions or assistance, contact the Financial Assistance Unit at (984) 974-3425 or toll-free at (866) 704-5286. Hours of
operation are Monday – Thursday 8:30 a.m. – 4:30 p.m. and Friday 8:30 a.m. – 12:30 p.m.

UNC Health Financial Assistance Unit

UNC Financial Assistance Application □ Patient Deceased
Submit via My UNC Chart or secure fax: 984-974-6454 or
Mail attention UNC Financial Assistance Unit, 500 Eastowne Drive 2nd Floor, Chapel Hill, NC 27514
For questions or assistance, call the Toll-free Financial Assistance Line 866-704-5286 or local 984-974-3425

I: NC Medicaid Eligibility Requirement

If you do not have health insurance and have not applied for NC Medicaid in the past 12 months, contact your local county
Department of Social Services or our office at 866-704-5286 or 984-974-3425 for eligibility screening.
Have you applied for NC Medicaid in the last 12 months? If yes, what was the outcome?
□ Yes □ No □ Approved □ Denied □ Pending □ Not Eligible
II: Patient Information
Name (Last, First, Middle Initial) Birth Date (mm/dd/yyyy) Guarantor No. or Medical Record No.

Address City State ZIP Code

Phone Number Email Address (optional) Marital Status

□ Single □ Married □ Divorced □ Separated □ Widow □ Minor
Employment Status Employer Name Employer Phone Number
□ Employed □ Self-Employed □ Unemployed
□ Retired □ Disabled □ Student □ Minor
III: Spouse or Guarantor (if patient is a minor under 18 years old)
Name (Last, First, Middle Initial) Birth Date (mm/dd/yyyy) Phone Number

Employment Status Employer Name Employer Phone Number

□ Employed □ Self-Employed □ Unemployed
□ Retired □ Disabled □ Student
IV: Household Dependents
Adults and/or minor dependents included on your Federal tax return that you provide more than 50% support.
Full Name Relationship Date of Birth Medical Record No.
1.
2.
3.
4.
V: Family Gross Income and Assets

Most recent 30 days of income for the patient, spouse or guarantor, and all household dependents 18 years of age and older. Please
send proof of monthly income by providing: pay wages, award letters, tax returns, letter from the employer, profit and loss statements
for self-employment, complete statements, and benefits letters. *Do NOT send originals.*
If you do not have any income, please include a letter of support, signed and dated, from the person who provides you with
assistance.

Banking: Do you have a bank account? □ YES □ NO Bank Name(s):

Type of account you and/or your spouse have: □ Checking □ Savings □ Investments □ Retirement
Include most recent statement(s) for all accounts (all pages). Last 4 digits of the account number must be visible.
UNC Financial Assistance Application
Submit via My UNC Chart or secure fax: 984-974-6454 or
Mail attention UNC Financial Assistance Unit, 500 Eastowne Drive 2nd Floor, Chapel Hill, NC 27514
For questions or assistance, call the Toll-free Financial Assistance Line 866-704-5286 or local 984-974-3425

Property: Do you own Real Estate OTHER than your primary residence? □ YES* □ NO
*If yes, include property Tax document. If a rental property, provide proof of rental income.

Taxes: Do you file taxes? □ YES* □ NO

*If yes, include the most recent Federal Tax Return including all schedules.

VI: Advocate (Optional)

If you have an advocate who is assisting you with the application process, please include the name and phone
number. By providing the advocates contact information you give us permission to speak to the advocate on your
behalf.
Name of Advocate: Phone:

Additional Comments:

VII: Signature and Date Required

I certify that all information listed is true to the best of my knowledge. I understand that fraudulent or misleading information will make
me ineligible for any financial assistance. I give permission for UNC Healthcare System and all affiliated clinics, hospitals, and entities to
verify the information provided on this application.
Patient Signature Sign Date (mm/dd/yyyy)

Guarantor Signature (if patient is a minor under 18 years old) Sign Date (mm/dd/yyyy)
NC Residency Requirements

In order to meet North Carolina state residency requirements, an individual must be domiciled in North Carolina. A person is domiciled in
North Carolina if North Carolina is his/her fixed, established, or permanent place of residence with the intention to remain there permanently
or for an indefinite period.

To verify NC residency, provide two documents from the list below. The documents must be in the name of applicant or applicant’s legal
spouse and show the current North Carolina address.

a. A valid North Carolina drivers’ license or other identification card issued by the North Carolina Division of Motor Vehicles.
b. A current North Carolina lease or mortgage document, bank statement, or current utility bill.
c. A current North Carolina motor vehicle registration.
d. A current North Carolina voter registration card.
e. Tax return for the applicant or the applicant’s legal spouse.
f. A document verifying that the applicant is employed in North Carolina.
g. One or more documents proving that the applicant’s home in the applicant’s prior state of residence has ended, such as closing of a
bank account, termination of employment, or sale of a home.
h. A document showing that the applicant has registered with a public or private employment service in North Carolina.
i. A document showing that the applicant has enrolled his children in a public or a private school or a child care facility located in North
Carolina.
j. A document showing that the applicant is receiving public assistance (such as Food Stamps) or other services which require proof of
residence in North Carolina. Work First and Energy Assistance do not currently require proof of NC residency.
k. Records from a health department or other health care provider located in North Carolina.
l. A written declaration from an individual who has a social, family or economic relationship with the applicant, and who has personal
knowledge of the applicant’s intent to live in North Carolina permanently, for an indefinite period of time, or residing in North
Carolina in order to seek employment or with a job commitment.
m. A document from the US Department of Veteran’s Affairs, US Military or the US Department of Homeland Security verifying the
applicant’s intent to live in North Carolina permanently or for an indefinite period of time, or that the applicant is residing in North
Carolina to seek employment or has a job commitment.
n. Official North Carolina school records, signed by school officials, or diplomas issued by North Carolina schools (including secondary
schools, colleges, universities, community colleges), verifying the applicant’s intent to live North Carolina permanently or for an
indefinite period of time, or that the applicant is residing in North Carolina to seek employment or with a job commitment.
o. A document issued by a foreign consulate verifying the applicant’s intent to live in North Carolina permanently or for indefinite
period of time, or that the applicant is residing in North Carolina to seek employment or has a job commitment.

NC Residency Declaration *Complete this section ONLY when NC Residency Documents CANNOT be provided*

I verify that I CANNOT provide two North Carolina state residency verification documents.
By signing below I affirm and represent that I am a North Carolina resident.
I hereby declare that the above information is true and accurate. I understand that this declaration form is used to help verify
that I meet North Carolina state residency requirements for UNC Health Care Financial Assistance. I understand that a false or
misleading declaration by me may result in Charity Care adjustments for which I would not otherwise have qualified, and may
subject me to civil and criminal penalties.

Patient Signature: Sign Date:

Address, city, state and zip code Primary Phone: