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Financial Assistance Application
Patient/Guarantor Information
Patient’s Name: __________________________________________________________________________
Guarantor’s Name (if patient is under 18 years of age): __________________________________________
Patient’s Address: ________________________________________________________________________
City: ______________ State/ZIP: _______________________ Patient’s Date of Birth: _______________
Patient’s Medical Record Number: __________________
Current Marital Status: □ Single □ Married □ Separated □ Divorced □ Widowed
Spouse’s Name: __________________________________________________________________________
Spouse’s Address (if different from patient): __________________________________________________
City: _______________ State/ZIP: ______________________ Spouse’s Date of Birth: _________________
Spouse’s Medical Record Number: __________________
Note: If you are married, then spouse’s financial information and signature is required in order for application to be
processed.
Household Size/Dependents (including yourself & spouse): ______________________________________
Please provide dependents name, Date of Birth, and Medical Record Number (if applicable)
Household Income (Gross): ________________________________________________________________
Income is defined as wages, profits from business, rental income from rental properties, social security
income [SSI/SSDI], income from investments, retirement/pension, alimony, etc.
Patient/Guarantor
□ Employed
Self-Employed
Unemployed
Full time student
Dependent on Others
Retired
Spouse
□ Employed
□ □ Self-Employed
□ □ Unemployed
□ □ Full time student
□ □ Dependent on Others
□ □ Retired
Please send proof of monthly household income by providing one of the documents listed below. If you
claim dependents you must provide a tax return.
(Pay Stubs, SSI/Disability, W2/Retirement/Pension, Tax Returns, Letter from Employer).
If no income, please provide explanation of how you pay daily living expense:
Please Check Box if you authorize us to update your demographic information (Address, Marital Status, etc.)
Patient/Guarantor’s Signature: _______________________________________ Date: __________________
Spouse’s Signature: ________________________________________________ Date: __________________
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