Department of State Hospitals
1215 O Street, MS-3
Sacramento, California 95814
DSH 10268 (12/2022)
Page | 1
Financial Assistance Program Application
Please return to:
Department of State Hospital
Attn: Patient Cost Recovery Section
1215 O Street, MS-3
Sacramento, CA 95814
Email Address: [email protected]
Instructions: Please complete Sections A – E to the best of your ability. Supporting documentation may be
attached to the application and sent along with the application to the address listed above.
Section A
Patient Information
Patient First Name Middle Name Last Name Date of Birth
Primary Address City State Zip Code
Secondary Address City State Zip Code
Check the following if they apply and if so; provide additional information below:
☐ Guardian/Conservator ☐ Representative Payee ☐ Power of Attorney
First Name Last Name Date of Appointment Phone Number Email
Mailing Address City State Zip Code
Family Member Information
Patient’s Marital Status:
☐
Single
☐
Married
Number of Dependents:
Please list all members of your household and their relationship to you below:
First Name Last Name Relationship
First Name Last Name Relationship
First Name Last Name Relationship
Department of State Hospitals
1215 O Street, MS-3
Sacramento, California 95814
DSH 10268 (12/2022)
Page | 2
Section B
Health Insurance Coverage
Do you presently have Health Insurance?:
☐
Yes
☐
No
If you answered checked the ‘Yes’ box, provide additional information below:
Primary Insurance Company Name Policy Holder
Policy/Subscriber ID Number Group Number
Relationship to Policy Holder: ☐ Self ☐ Spouse ☐ Parent ☐ Other
If you have a second health insurance policy, provide the following information:
Secondary Insurance Company Name Policy Holder
Policy/Subscriber ID Number Group Number
Relationship to Policy Holder: ☐ Self ☐ Spouse ☐ Parent ☐ Other
Section C
Income and Assets
Instructions: Please list monies received in the Monthly Amount Received column. If not applicable, please list
as ‘N/A’. Please include supporting documentation with the application when it is submitted. Non-countable
income is protected from collections and payment towards debt so does not need to be reported. See
Attachment 1 for additional types of non-countable income.)
Source
Monthly Amount Received
Employment Income
Supplemental Security Income
Disability Benefits
Veteran’s Benefits
Railroad Retirement
Support from Spouse, Parent or Dependents
Taxable Retirement Benefit
Rental Income
Other (describe):
Financial Accounts
Instructions: Please list any bank accounts you own and their value below. If additional space is needed use
Section E to add additional bank account information.
Department of State Hospitals
1215 O Street, MS-3
Sacramento, California 95814
DSH 10268 (12/2022)
Page | 3
Type of account:
☐
Checking
☐
Savings
☐
Other _____________________
Bank Name: Address:
Account Number (Last 4 digits only): Current Balance:
Type of account:
☐
Checking
☐
Savings
☐
Other _____________________
Bank Name: Address:
Account Number (Last 4 digits only): Current Balance:
Are you the beneficiary of a Trust?
☐ Yes ☐ No (if yes, please provide trust name, type, and trustee contact
information using Section E)
Miscellaneous Assets
Instructions: Please list any stocks, bonds, or cryptocurrency holdings you own and their value below. If
additional space is needed use Section E.
Description
Value
Real Property
Instructions: Please list any real property you own. If additional space is needed use Section E. Please also
indicate which property, if any, you are claiming as your primary residence.
Description/Address
Primary Residence (yes/no)
Section D
Monthly Living Expenses
Monthly living expenses cover:
☐
Only yourself
☐
Yourself and dependents.
Expense Type
Monthly Amount
Health Insurance Premiums (including dental and vision)
Legal Obligations (Alimony, child support, etc.)
Transportation (car payments, insurance, gas, public transportation fees, etc.)
House Payments (mortgage, rent, home insurance, property taxes, etc.)
Food, clothing, and other household supplies
School or childcare expenses
Utilities (gas, electricity, water, garbage, telephone, etc.)
Other:
Total Monthly Expenses
Department of State Hospitals
1215 O Street, MS-3
Sacramento, California 95814
DSH 10268 (12/2022)
Page | 4
Section E
Additional Considerations
Instructions: Please list any additional information that you feel will be relevant to DSH’s consideration of your
application for financial assistance, including additional bank account or stock and bond information. If you
need additional space, please list the information on a separate sheet of paper and attach to the application.
I certify the above information to be accurate and complete. I understand that the Department
of State Hospitals (DSH) reserves the right to verify all information supplied and that I may be
required to provide proof of the information I am providing. I agree to notify the DSH-
Sacramento Trust Office at (916) 654-1501 or DSHSacTrustOffice@dsh.ca.gov of any change
in my financial information within 10 days of the change.
I am the:
☐
Patient
☐ Patient’s Representative (Relationship to Patient ________________________)
Print Name Signature Date Email Phone
Address City State Zip
