FINANCIAL ASSISTANCE PROGRAM
Enclosed is the Memorial Hospital and Health Care Center Financial Assistance application. This application will be used to determine full or partial financial assistance on qualifying bills.
Complete financial disclosure and supportive documentation must be provided and will be
used to evaluate your request for a financial assistance write-off. Please complete the Financial Assistance application and returnit to us within 21 days.
The following information must be submitted with the application:
1. A letter that includes all circumstances which affect your income.
2. Your most recent Federal Tax and W2 forms along with a current bank statement.
3. Your two most recent payroll check stubs, even if you no longer work there.
4. Proof or a copy of any Social Security, disability and/or pension income.
5. Unemployment income verification, if applicable.
6. A list of your medical bills – include total amount owed and to whom.
7. Out-of-pocket expense for prescription medications, monthly or yearly.
After this information is received your application will be reviewed and a determination made.
Please contact our office approximately 30 days for the results of the determination.
Thank you!
Patient Financial Services Department
Memorial Hospital Healthcare Center
(800) 852-7279 Toll Free
(812) 996-0637 for last names beginning with A-L
(812) 996-0413 for last names beginning with M-Z
Fax (812) 996-8544
MEMORIAL HOSPITAL AND HEALTHCARE CENTER
FINANCIAL ASSISTANCE APPLICATION
Full and complete financial disclosure is required in order to evaluate your request for financial assistance. Incomplete or insufficient information will result in a denial of your request.
Name______Date of Birth______SS#______
Spouse’s Name______Date of Birth______SS#______
Address______City______State_____Zip______
Telephone______MaritalStatus____Email Address______
Dependents and/or members living in your household
Name/Age Name/Age
______
______
______
______
Employer______Phone#______
Rate of Pay $______Hour/Week/Month Length of Employment______
Spouse’s Employer______Phone#______
Rate of Pay $______Hour/Week/Month Length of Employment______
Group Health Insurance and/or Private Health InsuranceYesNo
If no, explain why no health insurance coverage______
Have you applied for Medicaid YesNo
If you have and were turned down, what was the reason?______
Other Income Sources:
Applicant Spouse Other
Social Security$______mth$______mth $______mth
Pension/Retirement Funds$______mth$______mth $______mth
Welfare / Public Assist.$______mth$______mth $______mth
Food Stamps $______mth $______mth $______mth
Unemployment$______mth$______mth $______mth
Child Support$______mth$______mth $______mth
Interest Income / Stock /
Bond/CD Investments$______mth$______mth $______mth
Checking$______Savings$______Name of Bank______
Life Insurance Co Name______Cash Value______
Personal Property______Value______
Vehicles: ______Value______
Financial Obligations: (Monthly)
Rent $______Mortgage $______Phone: Basic $______Cell Phone $______
Electricity $______Gas/Propane $______Food $______Other $ ______
Insurance $______Clothing $______Education $______Charge Cards $______
Loans:(Whom do you owe?)
Financial Institution______Monthly Payment ______
Financial Institution______Monthly Payment $______
Other Obligations:______
Medical Obligations______
I understand that the information which I submit is subject to verification by this medical facility. I certify that the above information is true to the best of my knowledge.
Signature of Patient (Responsible Party) Date Phone Number
______