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For evaluation for the Financial Assistance Program, please include all the following items, as applicable:
o Benefit award letters (pension, unemployment, SSI, SSDI)
o Last 2 month bank checking statements (if no bank accounts, please note in comments)
o Letter explaining how you are meeting your daily living expenses
Patient/Financially Responsible Party
Name (First, Middle, Last)
Relationship to Patient
Birth Date (Month DD, YYYY)
Address City State ZIP Code
Phone Household Size (Patient, Spouse and Dependents) Marital Status
Employment Status
Full Time Part Time
Self Employed
Retired
Student
If unemployed, last day/month & year worked
Employer Employment Date (Month DD, YYYY)
Does the patient currently have insurance coverage?
Yes
No
Yes
Spouse/Partner
Full Name Relationship Birth Date (Month DD, YYYY)
1.
2.
3.
4.
Applicant Name (First, Middle, Last) Date
Financial Assistance Application
DO NOT SEND ORIGINAL DOCUMENTS
UW Health - Financial Assistance
7974 UW Health Ct , MC1010
Middleton, WI 53562
Phone: 877-278-6437 Fax: 608-662-4565
Staff Use: Please fax to 608-662-4565 or
inter-office to Mail Code 1010
No
If not, why? _____________________________________________________________________________________________
Name (First, Middle, Last)
Birth Date (Month DD, YYYY)
Phone
Address City State ZIP Code
Employment Status If unemployed, last day/month & year worked
Employer
Employment Date (Month DD, YYYY)
Dependents
Medical Record # (If Known)
Yes
No
Coverage: _______________________________________________________________________________________________
Weekly Income
Hrs/Week:
Pay($)/Hour:
Weekly Income
Hrs/Week:
Pay($)/Hour:
If not, has the patient applied for coverage through the Marketplace (Healthcare.gov)?
Does the patient participate in a Health Sharing Ministry Product?
Does the patient elect to not participate in a government funded insurance program for religious/cultural reasons?
Did the patient/financially responsible party file taxes last year?
Yes
No
Yes
No
Unemployed
Full Time Part Time
Self Employed
Retired
Student
Unemployed
o This Application, signed and dated
o Federal tax returns and supporting schedules (last years)
o Pay stubs (last months)
From which organizations are you applying for financial assistance?
UW HEALTH MERITER BOTH
