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

______