| FA Application July2016
Patient Name: (Last, First, MI) SSN # PID#
Patient Home Address Street City/State Zip Code
_____/________/___________ ________-_________-_________ Marital Status: □ Married □ Single □Widowed □ Separated □ Divorced
Date of Birth (Month/Date/Year) Telephone Number
If Married, Spouse’s Name: ______________________________
Employer Information: Patient Employed? □Yes □ No Spouse Employed? □Yes □ No
Patient’s Employer: _______________________________________ Spouse’s Employer: _____________________________________
Income: Please provide the income for each of the following person(s) in your household, where applicable:
Patient: □Full Time □Part Time -Total Hours/Week= ________ $_____________ □Hr □Wk □Bi-Wk □Month □Year
Spouse: □Full Time □Part Time -Total Hours/Week= ________ $_____________ □Hr □Wk □Bi-Wk □Month □Year N/A
Complete this income section only if the patient is a Minor (18 years & under):
Patient’s Mother or Legal Guardian: □Full Time □Part Time-Total Hours/Week= ________ $___________ □Hr □Wk □Bi-Wk □Month □Year
Patient’s Father or Legal Guardian: □Full Time □Part Time-Total Hours/Week= _________ $___________ □Hr □Wk □Bi-Wk □Month □Year
Total Annual Household Income: $ __________________ Total Outstanding Medical Bills: $ __________________
(Copies of medical bill documentation required within 2 weeks)
Income Verification: Acceptable household income documentation is listed below. Please submit required copies within 2 weeks.
Paycheck Remittance Employer Verification Workers Compensation or Unemployment Compensation Determination Letters
IRS Form W-2 Tax Return Governmental Assistance (Food stamps, CDIC, Medicaid, TANF)
Bank Statements SS Determination Letters Other ___________________ □None (Written Attestation form required)
Family Members: Provide the total number of people in the patient’s household: _______________
Please note: This number should only include the patient, patient’s spouse, and the patients’ dependents unless the patient is a minor; include the
patient, the patient’s parents and parents’ dependents (if any).
I understand Touchstone Medical Imaging may verify the financial information contained in this Financial Assistance Application (“Application”) in connection with
Touchstone Medical Imaging’s evaluation of this Application, and by my signature hereby authorize my employer or any individual listed on this Application to certify
or provide additional details with respect to the information provided in this Application. I certify that the statements made in this Application are true and correct, to
the best of my knowledge and belief, and are made in good faith. I am aware that falsification or misrepresentation of information on this Application may result in
denial of financial assistance. I further understand that some physicians and providers may not be employees of Touchstone. I understand that I may receive separate
bills from those providers and this financial assistance application will not apply to those balances due.
_____________________________________________ ___________________________________ ____________________________
Signature of Patient or Responsible Party Printed Name Date
For Internal Use Only:
□ Application information obtained by Touchstone Employee _____________________________________________________________________
in person or over the phone, no patient signature required. Touchstone Employee Name Printed Date
Notes Re: Income/Household Size: _____________________________________________________________________________________________________
Patient is verified Community Care Program? NO YES Program Name: _________________________________________________________________
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