HCAP Request Application Form | University Hospitals

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.

First Name

Middle Initial

Last Name

Street Address

City

State

ZIP Code

Country

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