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Health Care Financial Assistance Application 
Date      Patient Name          
SSN     Hospital Acct #      
Responsible Party Information: DO NOT USE N/A in any field         
Name       Address        
Responsible Party SSN:   City        
Responsible Party DOB   State     zip  
PHONE Number:       County      
To ensure faster processing of this application, PLEASE COMPLETE ALL SECTIONS OF INCOME information - circle and/or check all that apply; weekly, bi-weekly, month, year
INCOME AND MEANS OF LIVING DO NOT USE N/A √ or circle all that apply Plus DOLLAR amounts
[  ] EMPLOYED  Salary Amount $     HOURLY/   WEEKLY/   MONTHLY/ YRLY
EMPLOYER            
Employer Address:       Employer Phone#    
    full-time  part-time Hours per week_______                   How long employed _______
   
[ ]UNEMPLOYED  without Income     with compensaton in the amount of $_____________  
[ ]RETIRED  Receive monthly income of ___________    Receive Social Security gross amt of $______________
[ ]DISABLED   Receive Social Security Disability income of $_____________      other income $____________ 
Worker's Comp $__________    VA/Military $__________  Welfare $_________   Child Support $__________     Alimony $_________   Potential Compensated Income                                    Verified by:___________________
Other income  $   [ ] Student at      
Number Dependents in household:____________ Total living in Household__________      
Name of Dependents in household Relationship Age Share of Cost   
          [ ] Yes $    
             
          [ ] No [ ] Denied [ ] Sanctioned
               
Spouse Information:     Name:     SS#   DOB:  
Salary Amount $   HOURLY/   WEEKLY/   MONTHLY 
[  ] EMPLOYED  EMPLOYER            
Employer Address:       Employer Phone#  
  full time  part time                   How long employed __________  
[ ]UNEMPLOYED  without Income     with compensaton in the amount of $_____________  
[ ]RETIRED  Receive monthly income of ___________    Receive Social Security gross amt of $______________
[ ]DISABLED   Receive Social Security Disability income of $_____________      other income $____________ 
Worker's Comp $_________   VA / Military $__________  Welfare $__________  Child Support $__________       Alimony $___________       Other Income  $________________
                 
To ensure faster processing of application, provide as much information about yourself include good contact information or alternate numbers where you may be reached for any questions we may have.
APPLICATION will Expire on:
EXPENSES
  Amount  WHO PAYS ASSETS Amount Bank Name:    
Rent     How you are paying your expenses if have no  income  Checking        
Electricity     Savings        
Phone     Rent/Mortgage    
Gas     ___ Family member     Year/ Make / Model  
Food     ___ Girl/Boy Friend Auto        
Loans     __Other __________ Boat        
Drugs     _________________ Other:        
Credit Cards     _________________          
Medical Bills     MEDICAID SCREENING QUESTIONS  
IRS     1. Do you have biological children living in your home under 18 Years __
Cable     2. Are you physically unable to work, whether you are employed or not? __
Child Care/Support     3. Are you pregnant at this time       __
Life Ins.     4. Are you 65 years of age or older       __
Auto Ins.     5. Are you a U.S. Citizen       __
Health Ins.     6. Are you disabled or applying for disability at this time?   __
Other:   If you answer yes to any of these questions, CRS can screen for Medicaid.  
Total Expenses              
Total Adults over AGE 21 in household   Compensated Income = Total expenses/adults over21 x 12months= Comp IncomeYrly
FINANCIAL AID:            
Do you have Health Insurance   Is there any third party liability?    
Do you receive Food Stamps   How much per month      
Have you applied for assistance  Yes   No When What Agency      
What was you biggest expense last year            
Do you have proof of identification with a valid drivers license or valid ID  [ ] Yes   [ ] No    
If NO, please explain and sign verifying no valid ID:  
                 
        Signature:         
Briefly explain your need for assistance:          
                 
                 
                 
Attestation: By signing this form, I am saying that the information I am giving is true and complete to the best of my knowledge. I now have been advised that if I knowingly give wrong information I am liable for prosecution under state law 817.50 which states (1) whoever shall, willfully with intent to defraud, obtain or attempt to obtains goods, products, merchandise, or services from any hospital in this state shall be guilty of a misdemeanor of the second degree
Signature of responsible party Date      
Signature of Patient Date      
JACKSON HOSPITAL Patient Financial Services CHARITY USE ONLY:      
  Follow up call for: Income  Expenses  Date___________      CRS notified possible XB eligible   Minor children in HH, no XB, high SOC
Charity Eligible              Discount Eligible  ________%                 Not Eligible d/t  ________________________________________
Proof of Income required  Date provided_______________            SOC verified $______________   CRS notified on______________
FA form mailed to patient Date posted_________________  Date Received________________      
FINANCIAL COUNSELOR SIGNATURE: DATE
JH PFS FORM CA04202016
COMPLETION OF INFORMATION REQUIRED FOR CHARITY APPROVAL -ANY EXPENSES OVER 9,999 PROOF OF INCOME REQUIRED, SELF EMPLOYED WILL NEED TO PROVIDE PROOF OF YEARLY INCOME