ࡱ>  nbjbj 4xcc,JJJJJ^^^^ D^-(2NNNNN)))'''''''$_*-<B'J)))))B'JJNN'{ { { ) JNJN'{ )'{ { :$,x%N&b3% ''0-(&%RM-BM-x%M-Jx%)){ )))))B'B'W$)))-())))M-))))))))) :  Anderson Hospital 6800 State Route 162 Maryville, IL 62062 Financial Assistance Application Account Number(s) if known: ______________ 1. Patients Information _________________________________________________________________________________________________________ Last Name First Name Middle Initial Social Security Number Date of Birth _________________________________________________________________________________________________________ Street Address City State Zip Code _________________________________________________________________________________________________________ Mailing Address City State Zip Code __________________________________________________________ _________________________________________ Home & Cell Phone Number Work Phone Number Email address How long have you resided at this address? ______ Years ______ Months If residency at current address has been less than six (6) months, please provide proof of residency (utility bill, lease, mortgage, etc.) Marital Status: % Single % Married % Separated % Divorced % Widowed % Civil Union 2. Person Responsible for Paying the Bill (Guarantor, Partner or Spouse) _________________________________________________________________________________________________________ Last Name First Name Middle Initial Social Security Number Date of Birth _________________________________________________________________________________________________________ Address if Different from Patients Home & Cell Phone Number Work Phone Number _________________________________________________________________________________________________________ Name of Insurance Company Effective Date 3. Please indicate ALL people living in the household, including applicant: Use additional sheet of paper if needed NAME RELATIONSHIP TO PATIENT AGE SOCIAL SECURITY # DOCTORS NAME ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 4. Is this application for future or past services? % Future % Past Dates of Services:_________________________ 5. Were you an Illinois resident on the date of care? % Yes % No 6. Have you completed an Anderson Hospital Financial Assistance application within the last year? % Yes % No 7. In the last year, were you eligible for Medicaid benefits? % Yes % No 8. In the last year, did you receive food stamps, WIC or energy assistance? % Yes % No 9. Are you now unemployed? % Yes % No Please check all that apply: % Unable to work % Health Problems % Student % Injury % Laid off % Retired 10. Are you unable to work or go to school due to a physical impairment? % Yes % No If yes, what is the disabling condition or diagnosis? _____________________ How long will you be disabled?___________ 11. Please check if anyone in your household is covered by: % Health insurance % Medicare % Medicare Part D % Medicare supplement % Medicaid % Veterans benefits which family member(s):________________________ 12. Are you divorced or separated, or was a party to a dissolution proceeding, whether the former spouse or partner financially responsible for your medical care per the dissolution or separation agreement? % Yes % No 13. Were you involved in an alleged accident? % Yes % No 14. Were you a victim of an alleged crime? % Yes % No 15. HOUSEHOLD INFORMATION APPLICANT SPOUSE/PARTNER (If Applicable) NAME of household member: ________________________ __________________________ Name of employer: ________________________ __________________________ Employer address: ________________________ __________________________ Employer telephone number: ________________________ __________________________ Monthly Gross Income From: Employment : $ _______________________ $_________________________ Self-employment: $ _______________________ $_________________________ Workers Compensation: $ _______________________ $_________________________ Real Estate: $ _______________________ $_________________________ Unemployment: (since ___/___/___) $ _______________________ $_________________________ Retirement (Soc. Security, Pension): $ _______________________ $_________________________ Veterans pension, disability: $ _______________________ $_________________________ Private Disability: $ _______________________ $_________________________ Temp. Assistance. For Needy Families $_______________________ $_________________________ Alimony/Child Support: $ _______________________ $_________________________ Public Assistance/Food Stamps: $ _______________________ $_________________________ Other Income: $ _______________________ $_________________________ Checking, Savings and Investments: Checking Account Balances: $ _______________________ $_________________________ Savings & CD Account Balances: $ _______________________ $_________________________ IRAs, 403B, 401K, Stocks, Mutual Funds $_______________________ $_________________________ Health Savings /Flexible Spending Acct: $_______________________ $_________________________ Other Specify:_________________ $ _______________________ $_________________________ Other: Automobile: Year, Make and Model _______________________ _________________________ Recreational Vehicle: Year, Make and Model _______________________ _________________________ UNINSURED PATIENTS ONLY: If you meet Anderson Hospitals Presumptive Eligibility criteria, you will be notified in advance that you are not required to complete the portions of this application addressing monthly expense information. 16. HOUSEHOLD EXPENSES Monthly Rent Payment $_____________ or Mortgage Payment: $________________ Mortgage Loan Balance $______________ Do you own property other than a primary residence: % Yes % No If Yes, Value $_________ Mortgage balance $____________ If other property is a business, list address: ______________________________________________________________________ Monthly Loan Payment: _______________ Paid to:_______________________ For:____________________________________ Monthly Payments: Utilities: $_________ Insurance (Auto/Life Property) $_________ Other:____________ $ _________ Alimony/Child Support $_________ Health Insurance $_________ Other:____________ $ _________ Child Care $_________ Healthcare Bills $_________ Other:____________ $ _________ Living (gas, food, clothes) $_________ Medications $_________ Other:____________ $ _________ 17. OTHER SUPPORTING INFORMATION Please describe your personal situation and your reasons for requesting assistance: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ If your financial assistance application is showing no income at all, please describe how you provide for your everyday living expenses such as housing, food, clothing, etc.: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________>^ °n_P_>,>#hUh46CJOJQJ^JaJ#hUhb6CJOJQJ^JaJh&OM5CJOJQJ^JaJhb5CJOJQJ^JaJ#hbhb5CJOJQJ^JaJ#hbhqC55CJOJQJ^JaJhqC55CJaJhTn5CJaJhqC5hqC55CJaJ#hnhqC55CJOJQJ^JaJ#hnh m5CJOJQJ^JaJ hqC5h0CJOJQJ^JaJ4jh^mh-CJOJQJU^JaJmHnHu*>   " gd,m$gd,gdbgdqC5gd&OMm$&d-DM Pgd6m$ &d P gdqC5ddd[$\$gdqC5m$ ddd[$\$^ `gd mm$      ! 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NEEDED DOCUMENTATION AND ASSIGNMENTS OF RIGHTS Read Carefully You must provide copies of the following documents with the application. Needed Documentation __________ Proof of Income last 3 paycheck stubs __________ Last years Federal Tax Return and W2s __________ Last 2 statements for all Checking, Savings, Stocks, Bonds, Annuities, etc. __________ Other information requested by Anderson Hospital (i.e. Medicaid Denial letter if applicable) I certify that the information in this application is true and correct to the best of my knowledge. I will apply for any state, federal or local assistance for which I may be eligible to help pay for this hospital bill. I understand that the information provided may be verified by the hospital, and I authorize the hospital to contact third parties to verify the accuracy of the information provided in this application. I understand that if I knowingly provide untrue information in this application, I will be ineligible for financial assistance granted to me may be reversed, and I will be responsible for the payment of the hospital bill. 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