FOR INTERNAL USE ONLY
Application Taken By: ____________________________________________________________________________________________
Today’s Date: ________________________________________________________________ Date Referred: _________________________
Referred By:____________________ Reason for Referral: ______________________________________________________________________
Ins: ________________________________Guarantor #(s): _______________________________ MRN #: _______________________________
Admit/Discharge Date(s): ______________________________________________________________________________________________
Diagnosis: ___________________________________________________________________________________________________________
Procedure:______________________________________________________________________________________________________
Est. Charges: __________________________ Est. Pt. Bal.: __________________________ Met 12/mo LOD Criteria?: ______________
If yes, why?: _________________________________________________________________________________________________________________
Patient Information:
Patient Name: ________________________________________________ DOB: _________________________________
Social Security Number: ______________________________ County of Residence: _____________________ Marital Status: ___________________
Mailing Address:______________________________________________ City: ________________________________ State: ____ Zip: _______
Physical Address: _____________________________________________ City: ________________________________ State: ____ Zip: _______
Home #: _______________________Work #: _______________________________ Cell #: ______________________ Email Address: _______________
Is the patient a U.S. citizen? _______________ If no, is the patient a legal resident? ___________________ Length as legal resident? : _______________
Visa type: ___________________ Is the patient pregnant?: ______________
Immediate Family Members Living in the Home (Include spouse and children younger than 18)
Relationship: __________ Name: _______________ DOB: ________________ SSN: ________________ Medicaid Recipient?: ______________
Relationship: __________ Name: _______________ DOB: ________________ SSN: ________________ Medicaid Recipient?: ______________
Relationship: __________ Name: _______________ DOB: ________________ SSN: ________________ Medicaid Recipient?: ______________
Relationship: __________ Name: _______________ DOB: ________________ SSN: ________________ Medicaid Recipient?: ______________
Relationship: __________ Name: _______________ DOB: ________________ SSN: ________________ Medicaid Recipient?: ______________
Relationship: __________ Name: _______________ DOB: ________________ SSN: ________________ Medicaid Recipient?: ______________
Employment Information for Patient/Parent/Legal Guardian/Spouse
Currently Employed?: _____ Employer: ___________________________________ How Long at Current Empl oyer: ____________________
Employee: __________________________________________________ Relationship to Patient: ________________________________________
Date Last Worked: ______________ Hourly Wage: ____________________________ Hours Worked per Week: ___________________________
How Often Paid: _____________________________________________ Monthly Gross Pay: ___________________________________________
Date Last Worked: ___________________________________________ Income While Out of Work: ___________________________________
Employment Information for Patient/Parent/Legal Guardian/ Spouse
Currently Employed?: _____ Employer: ___________________________________ How Long at Current Employer: ____________________
Employee: __________________________________________________ Relationship to Patient: ________________________________________
Date Last Worked: ______________ Hourly Wage: ____________________________ Hours Worked per Week: ___________________________
How Often Paid: _____________________________________________ Monthly Gross Pay: ___________________________________________
Date Last Worked: ___________________________________________ Income While Out of Work: ___________________________________
Additional Income (Alimony, Current Accessible Trust Fund, Child Support, Disability, Interests and Dividends, Public Assistance, Real Estate, Rentals and Leases,
Retirement, Settlement Income, Social Security, SSI, Survivor Income, Unemployment, Veteran's Benefit, Work First Family, etc):
Type: ________________________ Monthly Amt.: ________________ Received by: _________________ Date Began: ___________________
Type: ________________________ Monthly Amt.: ________________ Received by: _________________ Date Began: ___________________
Type: ________________________ Monthly Amt.: ________________ Received by: _________________ Date Began: ___________________
Patient Financial Assistance Application
Addendum A
Yes
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