APPLICATION FOR PARTICIPATION (Continued)
SECTION III – Income Criteria
When determining eligibility for hospital care assistance, a spouse’s income and assets must be used for an adult; parent’s income
and assets must be used for a minor child. Proof of income must accompany this application.
Income is based on the calculation of either twelve months, three months or one month of income prior to the date of service.
Patient / Family Gross Income equals the lesser of the following:
18. SOURCES OF INCOME
Weekly Monthly Yearly
A. Salary / Wages Before Deductions ________________________
B. Public Assistance ________________________
C. Social Security Benefits ________________________
D. Unemployment & Workmen’s Compensation ________________________
E. Veteran’s Benefits ________________________
F. Alimony / Child Support ________________________
G. Their Monetary Support ________________________
H. Pension Payments ________________________
I. Insurance or Annuity Payments ________________________
J. Dividends / Interest ________________________
K. Rental Income ________________________
L. Net Business income (self employed/
verified by independent source) ________________________
M. Other (strike benefits, training stipends,
military family allotment, income from ________________________
estates and trusts)
N. Total ________________________
SECTION IV – Certification By Applicant
I understand that the information which I submit is subject to verification by the appropriate health care facility and the Federal or
State Governments. Willful misrepresentation of these facts will make me liable for all hospital charges and subject to civil penalties.
If so requested by the health care facility, I will apply for governmental or private medical assistance for payment of the hospital bill.
I certify that the above information regarding my family size, income, and assets is true and correct.
I understand that it is my responsibility to advise the hospital of any change in status in regards to my income or assets.
19. Signature of Patient or Guarantor 20. Date