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 Healthcare Assistance Application

Name: _____________________________

Date of Birth: __________________ 

Address: ________________________________________________________

City State ________________ Zip:____________

Phone Number: _____________________ Social Security Number: _________________

Family Members Living In Household:

Dependant Name Birth Date Relationship Social Security Number
       
       
       
       
       

*If more attach sheet

SPOUSE/OR OTHER INCOME                                                 PATIENT INCOME 

Employer Name:____________________Employer Name:_____________________ Address:__________________________Address:___________________________

City, State, Zip______________________City, State, Zip______________________

Salary: (Gross Monthly) _______________Salary (Gross Monthly) ________________

Other Income Patient’s Monthly Income Spouse/Other Dependent’s Monthly Income
Social Security/Pensions/Annuities $ $
Unemployment or Workmen’s Comp Benefits $ $
Interest/Dividend Income $ $
Child Support/Alimony $ $
Veteran’s Benefit $ $
Rental Income $ $
Other $ $

ASSETS

Real Estate:Own ____ Rent____   Bank:Name/Address  
       
Market Value: $ Bank:Checking $
Amount Owed: $ Savings $
Auto/Truck/Type:   IRA/ Tax Sheltered Annuities $
    Life Insurance: $
Market Value: $ Money Market: $
Motorcycles, Boats, Campers, Etc.:   Stocks, Bonds, CD’s  
    Rental Property Owned: $
Market Value: $ Business Property Owned: $
    Other:  

MONTHLY EXPENSES

Rent or House Payments: $ Medical Insurance: $
Electric, Propane, Oil: $ Life Insurance: $
Water/Sewer: $ Other Medical Bills: $
Trash: $ Entertainment: $
Telephone: $ Auto Insurance: (Annual) $ $
Mobile Telephone: $ Property Tax: (Annual) $ $
Child Care: $ Other Loans: $
Food and Supplies: $ Misc. (Specify_________) $
Auto Payments: $   $
TV, Cable, Dish, etc,: $   $
Credit Card: $ Total Monthly Expenses: $

I/We do hereby certify that the information provided above is accurate and a true representation of my/our financial information.I/We understand that this application must be completed and returned to the Financial Counselor within 90 days of discharge for self pay patients.For patient’s covered by insurance the application must be received within 90 days from the date of payment or valid denial.I/We understand that insurance payment or valid denial and completion of this application does not relieve me/us of the financial obligations to Ferrell Hospital.I/We also understand that the falsification of any information submitted with this application will result in denial of application. I/We agree to provide the necessary verification of my/our income and authorize Ferrell Hospital to make all inquires that Ferrell Hospital deems necessary to verify the accuracy of the statements made herein, including but not limited to procuring a credit report from the credit bureau and/or other financial institutions.Ferrell Hospital reserves the right to deny any application upon their review. Date: ____________________________ Signed: ______________________________________

Date: ____________________________ Signed: _______________________________________

 

EMPLOYEE WAGE FORM (To Be Completed And Signed By Employer)

Employee Name: ________________________________________________________

Employee Social Security Number: __________________________________________

Employer Name: ___________________________________________________________

Telephone ______________________________________ Ext. __________________________ Address: ______________________________________________________________________ ______________________________________________________________________

WAGES FOR THE LAST 90 DAYS OR 3 MONTHS

WEEK PAY PERIOD ENDING GROSS WAGES
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1. Is the employee currently working? __________ (yes/no), If no, when was the last day worked? __________

2. If the employee is not currently working, will the employee be returning to work? __________ (yes/no) Expected return date __________

I certify the wage information regarding the person named above is true and accurate.

Date: ______________________ Signed: ______________________________________ Signature of Employer or Employer’s Representative

 

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