Unity Medical & Surgical Hospital Financial Assistance Application

UNITY MEDICAL & SURGICAL HOSPITAL

FINANCIAL HARDSHIP APPLICATION

Application/Evaluation cannot be processed or assessed without income verification. If you have no income, please provide explanation of how your living expenses (housing, food, utilities, etc.) are paid.

Account Number(s):______

Patient Name:______Date of Birth:______

Address:______Telephone #:______

Social Security#:______Balance Totals:______

Provide the Following on All Household Members.

NameDate of BirthRelationship to Patient

______

______

______

______

______

______

Income from Employment

Person EmployedEmployerGross PayPer

______Wk 2 Wks Month

______Wk 2 Wks Month

______Wk 2 Wks Month

Household Income from Other SourcesAmount per Month

Child Support/ Alimony Received (only if patient is recipient)……………….. $______

Food Stamps/ TANF/ Foster Care/ Township Trusty/ Church…………………… $______

Income Assistance/ Project SAFE/ Lunch Programs, etc……………………….. $______

Pension…………………………………………………………………………… $______

Rental Property…………………………………………………………………… $______

Social Security/ Social Security Disability……………………………………….. $______

Stocks, Bonds, Annuities, Interest………………………………………………… $______

Unemployment or Worker’s Compensation……………………………………… $______

Other:______$______

Total Monthly Gross Income: $______

Unity Medical & Surgical Hospital Financial Assistance Application – Page 2

Assets

Cash on Hand…………………………………………………………………….. $______

Checking Account Balance:Bank: ______$______

Savings Account Balance:Bank: ______$______

Stocks, Bonds, IRA, Certificates of Deposits Type/Bank______$______

Real Estate (Primary Residence)………………………………………………….. $______

Other Real Estate:Location______$______

Vehicles:Year/Make/Model ______Value  $______

Year/Make/Model______Value  $______

Year/Make/Model______Value  $______

Vehicle Loan Balance______$______

Total Assets: $______

Household Liabilities/Expenses

Cable Television / Satellite per Month …………………………………………… $______

Child Support / Alimony Paid per Month ………………………………………... $______

Credit Card Payments per Month(Total Credit Balance______) $______

Grocery Expense per Month ……………………………………………………… $______

Insurance Premiums per Month:Life____ Auto_____ Home____ Health_____ $______

Internet Service Provider/ DSL per Month ………………………………………… $______

Loan Payments per Month(Total Loan Balance______) $______

Medical Bills per Month(Total Medical Bills______) $______

Other Monthly Payments:Type______Balance______$______

Type______Balance______$______

Rent/Mortgage per Month:(Mortgage Balance______) $______

Telephone…………………………Cell______Home______$______

Transportation per Month …………………………………………………………. $______

Utilities per Month ………………………………………………………………… $______

Total Monthly Payments: $______

Unity Medical & Surgical Hospital Financial Assistance Application – Page 3

Other Circumstances We Should Consider In Assisting You: ______

****Please Include Verification of Income****

IRS Form W-2

Paystubs/Unemployment vouchers (3 most current months)

Tax Return(most current year filed)

Bank Statement (3 most current months)

Social Security/VA Benefits/Pension/Retirement letters

Notarized Letter (when necessary)

I understand Unity Medical & Surgical Hospital may verify the financial information contained in this Financial Assistance Application (“Application”) in connection with the Hospital’s evaluation of this Application, and by my signature, does hereby, authorize my employer to certify the information provided in this Application. I also authorize Unity Medical & Surgical Hospital to request reports from any and all credit reporting agencies,as well as the Social Security Administration. I am aware that the falsification of information on this Application may result in the denial of my financial assistance.When application is received, only current balances due will be taken into consideration for assistance. Unity Hospital will not refund any self-pay payments.

Signature: ______Date: ______

Witness: ______Date: ______

Patient Access Coordinator: ______Date: ______

Business Office Director: ______Date: ______

Chief Financial Officer: ______Date: ______

Chief Executive Officer: ______Date: ______

Revised – 1-11-2013