Financial Assistance Application
Admit Date:
HAR #:
Telephone#:
Date of Birth:
Patient Name:
__________________________________________
Social Security #:
Marital Status: S M D X W
Physical Address:
__________________________________________
Mailing Address:
______________________________________
HOUSEHOLD COMPOSITION (PERSON/PERSONS LIVING AT HOME)
NAME (Last, First, Middle) SEX AGE DOB RELATIONSHIP ANNUAL INCOME
ANNUAL INCOME INFORMATION
(PREVIOUS 12 MONTHS FROM DATE OF ADMISSION)
#1 PATIENT/GUAR EMPLOYER (current):
__________________________
LENGTH OF EMPLOYMENT:
Phone#:
____________
If employed < 12 months, must complete section #2
Gross wages:
________________________________ ▢
Hourly
Weekly
Monthly
Yearly Number of hours per week:
Do you own the business?:
Yes
No
If Yes, please provide personal & business Tax Returns.
#2
EMPLOYER
(previous/past):
____________________________________
LENGTH OF
EMPLOYMENT:
Phone#:
Gross wages:
________________________________ ▢
Hourly
Weekly
Monthly
Yearly Number
of hours per
week:
#3
SPOUSE/SIG.
OTHER EMPLOYER (current):
LENGTH OF
EMPLOYMENT:
Phone#:
____________
If < 12 months, must complete section #4
Gross wages:
________________________________ ▢
Hourly
Weekly
Monthly
Yearly Number
of
hours per
week:
Do you
own
the
business?:
Yes
No
If Yes, please provide personal & business Tax Returns.
#4
EMPLOYER
(previous/past):
____________________________________
LENGTH OF
EMPLOYMENT:
Phone#:
Gross wages:
________________________________ ▢
Hourly
Weekly
Monthly
Yearly Number
of
hours per
week:
Retirement benefits:
Yes
No Amount
$:
Unemployment:
Yes
No Amount
$:
Disability benefits:
Yes
No
Amount
$:
Rental Income:
Yes
No Amount
$:
Other Household Income
Yes
No Amount $:
SS benefits:
Yes
No Amount $:
VA?
Yes
No Amount $:
IRA’s?
Yes
No Amount $:
_________________
ASSET INFORMATION
Name of Bank:
____________________________
Checking: $
Savings: $
Money Mkt: $
Stocks?
Yes
No $
Bonds?
Yes
No $
CD’s
Yes
No
$
Home: Own?
Yes
No Rent:
Yes
No Buying
Yes
No What is monthly payment? $
Do you own other property:
Yes
No If Yes, what is the location?
______________________________________________
Vehicle 1 Year:
Make:
_________________________
Balance owed or monthly payment: $
Vehicle 2 Year:
Make:
_________________________
Balance owed or monthly payment: $
Vehicle 3 Year:
Make:
_________________________
Balance owed or monthly payment: $
______________
MEDICAID/AFFORDABLE CARE ACT (ACA) QUESTIONNAIRE
Have
you
ever
applied
for
Medicaid/ACA?
Yes
No When:
Where:
______________________________
Comments:
_______________________________________________________________________________________________________
COMBINED GROSS INCOME FOR THE PAST 12 (TWELVE) MONTHS HAS BEEN $
________________________________________
AND THERE ARE
(# OF)
PEOPLE IN MY FAMILY. THE INCOME INFORMATION CAN BE VERIFIED BY CALLING THE ABOVE EMPLOYERS. ADDITIONALLY, I UNDERSTAND THAT IN
ACCORDANCE WITH FLORIDA STATUTES 817.50, PROVIDING FALSE INFORMATION TO DEFRAUD A HOSPITAL FOR THE PURPOSES OF OBTAINING GOODS OR
SERVICES IS A MISDEMEANOR IN THE SECOND DEGREE. FURTHER, THE UNDERSIGNED HEREBY CONSENTS TO THE HOSPITAL'S INQUIRIES INTO HIS/HER
CREDIT HISTORY IN CONFORMITY WITH THE LEGITIMATE BUSINESS NEEDS AND APPLICABLE LAWS, RULES, AND REGULATIONS.
IN THE EVENT THAT ASSETS OR A PAYMENT BECOME AVAILABLE, LEE HEALTH RESERVES THE RIGHT TO REVERSE THE ORIGINAL
ADJUSTMENT.
LEE HEALTH MAY REQUEST ADDITIONAL DOCUMENTS IN SUPPORT OF THIS APPLICATION, AS DESCRIBED IN THE FINANCIAL ASSISTANCE
POLICY.
I HEREBY CERTIFY THE ABOVE INFORMATION TO BE TRUE AND CORRECT.
Copies of the Lee Health Financial Assistance Policy and additional information are available at www.LeeHealth.org.
If you have any questions or need help, Financial Counselors are available at 800-809-9906
______________________________________________________ __________________ _____________________________________________________________
Patient/Guarantors Signature Date Witness Signature
______________________________________________________ __________________
Spouse Signature Date
FM# 2364 Rev. 12/15 Page 1 of 2
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