Financial Assistance Application – Keystone Behavioral Health

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Financial Assistance Application

Step 1 of 6

16%

Date of Application(Required)

Client #(Required)

Service Location(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)

First Middle Last

Date of Birth(Required)

Email(Required)

Address(Required)

Street Address City State / Province / Region County ZIP / Postal Code Country

Primary Phone #(Required)

Country Phone Number

Other Phone #

Country Phone Number

Other Phone #

Country Phone Number

Current Living Arrangements

Own

Rent

Homeless

Recovery/Transitional Housing

Housing provided by relative or friend

Employer Name

Employment Status(Required)

Full Time

Part Time

Self-Employeed

Unemployed

Student

If you are not working, how long have you been unemployed?(Required)

Household Size (patient, spouse, and dependents as reported on income tax filing)(Required)

Third Party Information

I have health insurance:(Required)

Yes

No

If yes, what type:

I have the availability of insurance through my employer or my spouse's/parent's employer:

Yes

No

Reason for Not Using Insurance:

I have applied for Medicaid:(Required)

Yes

No

If "No," was patient given information on how to apply for Medicaid?

Yes

No

Date Applied

If Approved, Medicaid ID #:

If denied, reason for denial:

Have you applied for insurance through the Healthcare Market Exchange?

Yes

No

Date Applied

What was the outcome (including deductible amount)?

Do you feel this insurance adequately covers your healthcare needs?

Yes

No

Household Members or Dependents

If more than 4, use separate page.

Name

Relationship

Date of Birth

Name

Relationship

Date of Birth

Name

Relationship

Date of Birth

Name

Relationship

Date of Birth

Co-Applicant Information

Relationship to Patient

Spouse / Domestic Partner

Parent

Other:

Co-Applicant Name

First Middle Initial Last

Date of Birth

Number of Dependents

(other than self & co-applicant)

Ages of Dependents

Primary Phone #:

Country Phone Number

Address

Street Address City State / Province / Region County ZIP / Postal Code Country

Address Type

Permanent

Temporary

Current Employer

Position

Address

Street Address City State / Province Region County ZIP / Postal Code Country

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.)

Employment

Applicant

Employment

Co-Applicant

Combined Monthly Income

Social Security

Applicant

Social Security

Co-Applicant

Combined Monthly Income

Disability

Applicant

Disability

Co-Applicant

Combined Monthly Income

Unemployment

Applicant

Unemployment

Co-Applicant

Combined Monthly Income

Spousal/Child Support

Applicant

Spousal/Child Support

Co-Applicant

Combined Monthly Income

Rental Property

Applicant

Rental Property

Co-Applicant

Combined Monthly Income

Investment Income

Applicant

Other

Co-Applicant

Combined Monthly Income

Other

Applicant

Other

Co-Applicant

Combined Monthly Income

Other

Applicant

Other

Co-Applicant

Combined Monthly Income

Other

Applicant

Other

Co-Applicant

Combined Monthly Income

Total Combined Monthly Income

If no one is employed, how are you being supported? Please explain how you take care of monthly expenses.

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.

Applicant Signature

Date

Co-Applicant Signature

Date

Authorized Agency Signature

Date

Can we help you or someone you know?

Call our main office at 803-324-1800 for a confidential screening. We will connect you with others in the community who can help you recover.

Call Us Today

Keystone Main Facility

199 S. Herlong Ave.
Rock Hill, SC 29732

Keystone Youth Center

1668 Herlong Ct.
Rock Hill, SC 29732

Keystone Prevention Center

1600 Ebenezer Rd.
Rock Hill, SC 29732

Call Us

803-324-1800

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Treatment
Prevention
Behavioral Health
- Paying for Counseling
- Resources
Support
About
Make a Payment
803-324-1800

facebook
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