Financial Assistance Application

Date of Application(Required)

Client Information

Print all information. If you are a minor (0-17 years of age), legal guardian's information will be required.
Name(Required)
Date of Birth(Required)
Address(Required)
Primary Phone #(Required)
Other Phone #
Other Phone #
Current Living Arrangements(Required)
Employment Status(Required)

Third Party Information

I have health insurance:(Required)
I have the availability of insurance through my employer or my spouse's/parent's employer:(Required)
I have applied for Medicaid:(Required)
If "No," was patient given information on how to apply for Medicaid?
Date Applied
Have you applied for insurance through the Healthcare Market Exchange?(Required)
Date Applied
Do you feel this insurance adequately covers your healthcare needs?

Household Members or Dependents

If more than 4, use separate page.
Date of Birth
Date of Birth
Date of Birth
Date of Birth

Co-Applicant Information

Relationship to Patient
Co-Applicant Name
Date of Birth
(other than self & co-applicant)
Primary Phone #:
Address
Address Type
Address

Income Information - Monthly Income Sources

(List the amount of monthly income from all sources, Income Includes gross wages or salary, not receipts from self-employment, regular public assistance payments such as AFDC or SSI Social Security, Veteran's Benefits, pension or other retirement income, unemployment compensation, worker's compensation, child support or alimony interest income, etc.)
Applicant
Co-Applicant
Applicant
Co-Applicant
Applicant
Co-Applicant
Applicant
Co-Applicant
Applicant
Co-Applicant
Applicant
Co-Applicant
Applicant
Co-Applicant
Applicant
Co-Applicant
Applicant
Co-Applicant
Applicant
Co-Applicant

Certification Signatures

I certify that all financial information provided is true and correct to the best of my knowledge. I understand that the information is to be used to ascertain my ability to pay for services provided.
Date
Date
Date