Fillable Mc4244-15 Patient Financial Assistance Application - MC4244-15

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Mc4244-15 Patient Financial Assistance Application - MC4244-15

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The Mc4244-15 Patient Financial Assistance Application - MC4244-15 form is 2 pages long and contains:

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Country of origin: US
File type: PDF

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Instructions: Complete application and attach copies of:
• Tax returns and supporting schedules (previous 2 years) • Pay stubs* (most recent 3 months)
• Social Security benefits* (if applicable) • Bank statements* (most recent 3 months for all accounts)
• On a separate page describe your need for financial assistance* • W-2 or Unemployment Statements*
*Not applicable for Barron, Cameron, Rice Lake, Mondovi, Osseo, Elmwood, Menomonie, WI or Albert Lea, MN Behavioral Health (including Fountain Centers)
Patient/Responsible Party
Name (First, Middle, Last) Social Security Number Birth Date (mm-dd-yyyy)
Address City State ZIP Code
Phone Household Size (Patient, Spouse and Dependents) Marital Status
Employment Status
Full time Part time Self employed Unemployed Student
Employer Name
Employment Length Unemployed Date/Length (mm-dd-yyyy) Are you claimed on another tax return?
Yes No
(If yes provide tax returns of those being claimed)
I have applied for or will apply for federal or state medical assistance or have verified my healthcare exchange plan eligibility.
Yes No Reason _________________________________________________________________________________
I have a lawsuit, settlement, personal injury, or liability claim pending.
Yes No Reason _________________________________________________________________________________
I have the availability of insurance through my employer or my spouse’s employer.
Yes No Reason _________________________________________________________________________________
I have previously applied for financial assistance at another Mayo Clinic facility.
Yes No Not sure
Where _______________________________________________ When _______________________________________________
Dependents (If more than 4 dependents use separate page)
Full Name Relationship Birth Date (mm-dd-yyyy)
1.
2.
3.
4.
Applicant Name (First, Middle, Last) Services Locations
Spouse/Partner
Name (First, Middle, Last) Social Security Number Birth Date (mm-dd-yyyy)
Employment Status
Full time Part time Self employed Unemployed Student
Employer Name
Employment Length Unemployed Date/Length (mm-dd-yyyy)
MC4244-15rev0519
Financial Assistance Application
Form content not retained in medical record.
For local storage only.
(complete fields or place patient label here)
Patient Name (First, Middle, Last)
Birth Date (mm-dd-yyyy) Room Number (if applicable)
Mayo Clinic Number
©2019 Mayo Foundation for Medical Education and Research Page 1 of 2
Next Page
Complete and print.
Reset Form
MC4244-15rev0519Page 2 of 2
Bank Account(s) Not applicable for Barron, Cameron, Rice Lake, Mondovi, Osseo, Elmwood, Menomonie, WI or Albert Lea, MN Behavioral Health (including Fountain Centers)
Bank Name Account Type Bank Name Account Type
Checking Checking
Savings Savings
Other Investments and Securities Other Investments and Securities
Property Not applicable for Barron, Cameron, Rice Lake, Mondovi, Osseo, Elmwood, Menomonie, WI or Albert Lea, MN Behavioral Health (including Fountain Centers)
Type Detail Estimated Value Unpaid Balance
Secondary Residence/Vacation Home
Land Number of Acres
Rental Property
Business/Farm Equipment
Other/Recreational Vehicle
Certification Signatures
I certify that all information listed is true and correct to the best of my knowledge. I understand that the information is to be used to ascertain my
ability to pay for services provided by Mayo Clinic or an affiliated entity and I give permission to Mayo Clinic and all affiliated clinics, hospitals
and entities to share the information as necessary to consider my financial assistance request. I hereby grant permission to Mayo Clinic, all Mayo
Clinic affiliates and representatives or agents to investigate the information contained herein, and to obtain credit reports.
Patient/Responsible Party Signature
Date (mm-dd-yyyy)
Patient/Responsible Party Printed Name (First, Middle, Last)
Spouse/Partner Signature
Date (mm-dd-yyyy)
Spouse/Partner Printed Name (First, Middle, Last)
Provide documentation for any of the following sources of income.
Income Description Source Monthly Income Amount
Interest/Dividends
Pension/Retirement
Rental/Property
Disability
Alimony/Child Support
Other
Insurance
Type Policy With Monthly Payment
Health
Medical Debt
Type To Whom Unpaid Balance Monthly Payment
Medical Doctor
Medical Hospital
Other
Financial Assistance Application
(continued)
(complete fields or place patient label here)
Patient Name (First, Middle, Last)
Birth Date (mm-dd-yyyy)
Mayo Clinic Number
Print
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Mc4244-15 Patient Financial Assistance Application - MC4244-15

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Completed 22 July 2020

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