Bad Debt and Charity Care Assessment Form
Complete this form to assess whether a patient or account meets the criteria for bad debt or charity care.
Account or Patient Reference
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessment Type
*
Bad Debt
Charity Care
Total Amount Owed (do not enter sensitive account numbers)
*
Primary Reason for Assessment
*
Please Select
Uninsured
Underinsured
Financial Hardship
Uncollectible Debt
Other
Financial Hardship Rating
*
No hardship
1
2
3
4
Severe hardship
5
1 is No hardship, 5 is Severe hardship
Assistance Previously Provided
None
Payment Plan
Prior Charity Care
Other
Assessment Details (summary of findings and justification)
Eligibility Recommendation
*
Qualifies for Bad Debt
Qualifies for Charity Care
Does Not Qualify
Assessor Name
*
First Name
Last Name
Submit Assessment
Should be Empty: