Patient Billing Industry Lab Diagnostic Partners Financial Assistance Application ILDP is committed to care for all patients regardless of their ability to pay. Patients who are unable to pay for services may be eligible for financial assistance. Please complete and return the following form to be evaluated for financial assistance.Applicant Name(Required) (First, Middle, Last)Services Dates(Required) Account Number(s)(Required) Instructions: Complete application and attach copies (no originals) of: Tax returns and supporting schedules (previous 2 years) Social Security/Disability, W-2 or Unemployment (if applicable) Pay Stubs* (most recent 3 months) Food Stamp Letters* (if applicable) Service Location(s)(Required) ILDP Ohio ILDP Tennessee ILDP Illinois Patient/Responsible PartyName(Required) (First, Middle, Last)Social Security Number(Required) Birth Date (Month DD, YYYY)(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Household Size (Patient, Spouse, and Dependents)(Required) Marital Status(Required) Employment Status(Required) Employed Unemployed Employer Name Employment Length Unemployed Date/Length (Month DD, YYYY) Are you a student?(Required) Yes No Are you claimed on another tax return?(Required) Yes No (If yes provide tax returns of those being claimed)Is this the result of an auto or work-related accident?(Required) Yes No Spouse/PartnerName (First, Middle, Last)Social Security Number Birth Date (Month DD, YYYY) Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneHousehold Size (Patient, Spouse, and Dependents) Marital Status Spouse Employment Status Employed Unemployed Spouse Employer Name Spouse Employment Length Spouse Unemployed Date/Length (Month DD, YYYY) Are you a student? Yes No Are you claimed on another tax return? Yes No (If yes provide tax returns of those being claimed)Is this the result of an auto or work-related accident? Yes No Dependents Full Name Relationship Birth Date (Month DD, YYYY) Actions Edit Delete There are no Dependents. Add Dependent Maximum number of dependents reached. (If more than 3 dependents use separate page)CertificationI certify that all information listed is true and correct to the best of my knowledge. I understand that the information is to be used to ascertain my ability to pay for services provided by ILDP or an affiliated entity and I give permission to ILDP and all affiliated clinics, hospitals, and entities to share the information as necessary to consider my financial assistance request. I hereby grant permission to ILDP, all ILDP affiliates and representatives or agents to investigate the information contained herein, and to obtain credit reports.Patient/Responsible Party Signature(Required) Reset signature Signature locked. Reset to sign again Date (Month DD, YYYY)(Required) Spouse Signature Reset signature Signature locked. Reset to sign again Date (Month DD, YYYY) In 4 to 6 weeks, you will receive a letter to inform you if you are eligible for financial assistance. If you receive an approval letter, it does not mean that all services at ILDP are approved or that future services will be approved for financial assistance. Please call ILDP Patient Billing Customer Service Team at 888-274-7849 to reapply. You can also email or mail in a new application. If you receive a letter informing you are not eligible for financial assistance and wish to appeal the decision, you can appeal the decision by emailing, mailing, or faxing a completed ILDP Financial Assistance Appeal Application. Please note that the address below is for MAIL ONLY.Industry Lab Patient Billing Department 8122 Sawyer Brown Rd. Ste 210 Nashville, TN 37221 (615) 630-7799 - Phone (615) 630-7798 - Fax billinginquiry@ildp.comEmailThis field is for validation purposes and should be left unchanged.
