Instructions for Completing the Duke University Health System Financial Hardship Form
Section 1. Patient/Guarantor Information
Patient’s Name: Clearly print on the blank line the first name, middle initial, and last name of the patient
or guarantor. Patient’s !ddress: Clearly print on the blank line the address where you live including the
city, state, and zip.
Patient’s Date of Birth: Clearly print on the blank line your date of birth.
Patient’s Marital Status: Clearly print single or married.
Patient’s MRN/Guar ID: Clearly print the medical record number Duke Health has issued the patient or
the Guarantor’s ID # if the application is for a dependent’s balances;
Guarantor’s !ddress: Clearly print on the blank line the address where you live including the city, state
and zip.
Section 2: Spouse Information (may be skipped if you are single)
Spouse’s Name: Clearly print on the blank line the first name, middle initial, and last name of the patient
or guarantor’s spouse;
Spouse’s !ddress: Either clearly print on the blank line the address where your spouse resides or
indicate “Same” if you and your spouse reside at the same address;
Spouse’s Date of Birth: Clearly print on the blank line your spouse’s date of birth;
Section 3. Household Information
Number of Dependents: Clearly print the number of dependents in your household you can claim on
your taxes (children or adults who you financially provide more than 50% of their living expenses).
Total Monthly Household Income: Clearly print the amount of income from all sources your household
(yourself, your spouse, and dependents) receives monthly (including but not limited to wages, profits
from business, rental income from rental properties, social security income (SSI/SSDI), income from
investments, estates, trusts, alimony, child support, aid to dependent children, etc.)
Total Household Assets: Clearly print the value of all assets excluding the primary residence (including
but not limited to: Savings, Checking, Mutual Funds, Stocks, Bonds, Rental property value, etc.)
Required Documentation
The documents listed in this section are needed to help us determine if you qualify for charity care
under our financial assistance policy. If you do not have, or cannot produce the items listed, please
include an explanation as to why.
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