Apply for financial assistance

Welcome to the TotalCare Financial Assistance Program. We believe that your focus should be on your health, not the stress of a medical bill.

We have designed this program to ensure that our world-class emergency services remain accessible and affordable for our community. This form is a confidential way for us to understand your unique situation and find a financial resolution that fits your household budget. We are here to help, and we look forward to supporting you through this process.

You answer a few questions about your visit and your household.

You apply. You need no documents to start.
Your bill is placed on hold the moment you apply.
You add your documents when you have them, at your own pace.
We review your file once your insurer’s Explanation of Benefits has arrived and your file is complete. Then we update you with a decision within seven days.

Our assumptions on this screen (not part of the product)

The “Apply” buttons open this application in a new tab, at an address of its own. The real one would run apart from the website, on hosting set up for patient information, without advertising or analytics tags (this sample carries none). Who builds, hosts and runs it is still to be agreed.
A patient needs no account and no password to apply.
The two opening paragraphs are the welcome text of your form, word for word. The sample no longer says how long the application takes. “It costs nothing to apply” is gone from the start screen, as you removed it from the Financial Assistance page. The questions of your form are added to ours. Ours that your form does not have are kept: the date of birth, the emergency room, the insurance question, the relationship of a person who applies for the patient, and the agreement to messages. (changed after your email of October 19)

Application received

Thank you, . Your reference number is .

Your bill is on hold

On hold since . It stays on hold while your request is pending.

You signed this application as .

We sent a text message to the number ending in . It holds a link to your application, so you can come back at any time.

What happens next

Add your documents. Two are needed: your proof of income and a photo ID. You can add them now or later.
We review your file once your insurer’s Explanation of Benefits has arrived and your file is complete, and update you with a decision within seven days.

Sample tools (not part of the product)

No message is sent in this sample. Any number with ten digits and any six-digit code open the made-up application.

See the team's side of this (sample) (opens in a new tab)

Your application

Reference , for

Sample tools (not part of the product)

Show this application as

The dates are made up to fit each state.

See the team's side of this (sample) (opens in a new tab)

Your bill is on hold

On hold since . It stays on hold while your request is pending.

Where your application stands

Application received
Documents
Explanation of Benefits
Review
Decision

Documents

Proof of household income
You said you will send:
Needed
Photo ID
A driver’s license, a state ID or a passport.

Needed
Proof of Texas Residency
A recent utility bill (water, electric, or gas) or lease agreement helps us confirm you are a member of the local community we serve

Not required

Sample: the buttons only mark a document as received. Nothing is chosen or uploaded.

Updates

Your answers

Your estimate

A discount is taken off your share of the bill after insurance.

Additional eligibility criteria and documentation may apply. This calculator provides an estimate only and does not guarantee qualification or final approval.

Need help?

Questions about your bill? Call us at 817-916-0394.

Our assumptions on this screen (not part of the product)

Two documents are required: proof of household income and a photo ID. The proof of income counts as one document: whatever the patient checked under “Documentation & Verification”, one proof is enough. Your form asks for no photo ID; we kept it. “Proof of Texas Residency” is from your form and is not required. There is no deadline: while a required document is missing, the bill stays on hold. (changed after your answers of October 13)
The five steps of the tracker are ours. The file counts as complete as soon as the proof of income and the photo ID are in. You wrote “7 days after an EOB is generated”. The sample counts seven calendar days from the day the Explanation of Benefits arrives. If documents are still missing on that day, it counts from the day the file is complete. Calendar days, the day of arrival and that second rule are our reading. The patient sees the date. (changed after your answers of October 13)
The discount is taken off the patient’s share after insurance, as you wrote (“the patient’s responsibility portion”). The estimate says so too, in our words. The sample applies the highest discount of the tier. The bill here is made up: real amounts need a link to your billing system, or your team types them in. (changed after your answers of October 13)
The hold ends with the decision, and the sample names no due date. The patient can then pay online. You wrote: “Patients can request payment plans at the front desk or call us at 817-916-0394.” So the button for a payment plan is gone: after either decision, unless nothing is owed, this screen says, in our words, “To ask for a 0% interest payment plan, call us at 817-916-0394 or ask at the front desk.” Your team records the request in its workspace. “Pay my bill” opens the website’s existing page, which would have to show the reduced amount. (changed after your email of October 19)
A patient who is not approved sees both alternatives of your document, and under them how to ask for a payment plan (see number 20). Every applicant now has insurance, so the line about self-pay pricing reaches insured patients too: tell us if it should go. (changed after your email of October 19)
After sending, the patient cannot change the answers, and the sample has no way to appeal a decision.
The side your billing team works in is a sample of its own: the link is in the “Sample tools” boxes. Not shown: a Spanish version. (changed after your answers of October 13)
The sample tools have a new state, “documents missing, EOB in”: the Explanation of Benefits is in while documents are missing. While both are missing, the tracker shows “Documents” and “Explanation of Benefits” as current at the same time. (new, October 13)

Apply for financial assistance

Step 1 of 4. Who is the patient?

Step 2 of 4. Which visit is this about?

Step 3 of 4. Your household and income

Step 4 of 4. Contact, documents and signature

Sample tools (not part of the product)

Application received

Your bill is on hold

What happens next

Sample tools (not part of the product)

Your application

Sample tools (not part of the product)

Your bill is on hold

Where your application stands

Documents

Updates

Your answers

Your estimate

Need help?

Apply for financial assistance

Step 1 of 4. Who is the patient?

Step 2 of 4. Which visit is this about?

Step 3 of 4. Your household and income

Step 4 of 4. Contact, documents and signature

Sample tools (not part of the product)

Application received

Your bill is on hold

What happens next

Check my application

Sample tools (not part of the product)

Your application

Sample tools (not part of the product)

Your bill is on hold

Where your application stands

Documents

Updates

Your answers

Your estimate

Need help?