Financial Counseling Forms

There are several forms provided on this page that you should print out and use for your application process.  These forms are in PDF format and can be viewed using Adobe Reader.

Application for Financial Assistance - The application for financial assistance needs to be completed and brought in for your interview or completed and sent in with your documentation.     Solicitud para la Asistencia financiera

Approved Document List - There is a proofs form that has a the approved list of documents that need to be submitted for consideration of discounted services.   Please print this form and indicate on the form by checking off the documents which you are providing.  Provide any and all documents indicated on the list that fit your current financial situation.   Documentation will need to be provided under each category on the list.  The categories on the list proof of identification with a photo Id, two proof of residence documents, proof of household income, proofs of dependents (including spouse) and asset documents.  Most current year's Income Tax Return will need to be submitted from all patients.  See below for Special Instructions for SELF-EMPLOYED INDIVIDUALS and/or NOTICE OF NON-FILING   Lista de documentos en español aprobados

Notarized Letter - Should you need a notarized letter of support and/or residence, you are requested to use the official form on this website.   Please have the top part for the form completed by the person (must be notarized when they complete their portion) who provides support and/or residence and then see the bottom part of the letter for the "PATIENT'S RESPONSIBILITY".  If you are providing the notarized setter of support due to having very little or no income, you must first apply with your local County Indigent Health Program for their local indigent program and bring results for that application to your financial counseling interview.    Carta Notariada De Residencia O Apoyo

Deposit Guide for Services at UTMB - Deposits are required for all services at UTMB regardless of your financial classification.  Deposit is a fee paid in advance that is a partial payment toward the cost of a service.  Patients will be balanced billed for the remaining cost of their services.  These services include outpatient visits, tests, procedures, emergency room visits and inpatient admissions. Deposit amounts vary in these different areas based on estimated charges or services.   The deposit guide should be used as a general guide for each patient to give them an estimate of what could be expected for any particular service at UTMB.   If the physician makes a determination that you need a procedure or surgery, staff in that area would be able to inform you of what your specific deposit amount would be at that time.   The guide is divided into several different categories of financial responsibility.   The financial screening process identifies which category you would fall under.    Fee are subject to change at any time.  DEPÓSITO CALCULADO PARA LOS SERVICIOS EN UTMB

Special Instructions for SELF-EMPLOYED INDIVIDUALS and/or NOTICE OF NON-FILING: 
For self-employed individuals and/or individuals that have not filed a return in the most recent tax year, there are special requirements.   You must provide the entire copy of your most recent's year income tax return for proof of income.   If your income tax return is not prepared by a professional preparer with a Tax ID number on the copy of the return, UTMB is requiring that the individual obtain an official transcript copy of the income tax submission.   (If you do not file an income tax return, you are required to provide a notice of non-filing from the IRS acknowledging no tax return has been filed.  You would still request the IRS Transcript via this method.)  The transcript is obtained from the Internal Revenue Service (IRS) and is considered the official copy of your IRS return.  You must obtain the IRS transcript prior to your appointment for financial screening.  This form may be requested by contacting the IRS at 1(800)829-1040 or see the IRS web site for details.  The transcript can be ordered by completing a Form 4506-T (PDF) or calling 1(800)829-1040 and following the prompts in the recorded message.   There is no charge for the transcript and you should receive it in approximately 10 business days after requesting it.   Tax return transcripts are generally available for the current and past three years.  If the Form 4506-T is used to request the transcript, please have the IRS transcript sent back to you and then forward a copy to Financial Counseling via mail, fax, or drop it by our office.