Application Date

Date of Service

Patient Name

Account Number

Phone/Mobile

Patient Date of Birth

Social Security Number

Address

street address line 1

street address line 2

City

State

Zip Code

Was the patient a resident of Georgia at the time of service?

Yes

Did the patient have medical insurance at the time of service?

Yes

Was the patient an active Medicaid recipient at the time of service?

Yes

Please attach a copy of your insurance or Medicaid card to this application.

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INCOME:

All adult family members' income must be Income includes gross (before taxes) wages, rental income, unemployment compensation, social security benefits, public assistance, dividends and interest, etc.
"Family" is defined as follows:
(i) for persons 18 years of age and older, family means spouse, domestic partner and dependent children under 21 years of age, whether living at home or not;
(ii) for persons under 18 years of age, family means parents, caretakers, relatives, and other children under 21 years of age of the parent or caretaker relative. If the patient is a minor, the "family" is defined as the patient, the patient's natural or adoptive parents and the parent's other children (natural or adoptive) who live in the patient's home.

Family Member's Name

Age

Date of Birth

Relationship to Parent

Source of Income or Employer Name

Income for 3 months prior to date of service

Income for 12 months prior to date of service

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Family Member's Name

Age

Date of Birth

Relationship to Parent

Source of Income or Employer Name

Income for 3 months prior to date of service

Income for 12 months prior to date of service

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Family Member's Name

Age

Date of Birth

Relationship to Parent

Source of Income or Employer Name

Income for 3 months prior to date of service

Income for 12 months prior to date of service

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Family Member's Name

Age

Date of Birth

Relationship to Parent

Source of Income or Employer Name

Income for 3 months prior to date of service

Income for 12 months prior to date of service

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Family Member's Name

Age

Date of Birth

Relationship to Parent

Source of Income or Employer Name

Income for 3 months prior to date of service

Income for 12 months prior to date of service

Proof of income must be supplied at the time of application (e.g., three months of pay stubs, most recent tax return (IRS Form 1040), etc.).

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If you report $0 income, please provide a written statement of how you (or the patient) are surviving financially, including who provides food, shelter, transportation, etc. and how long you have been without income.

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Monthly Expenses

Monthly Rent / Mortgage

Car Payment

Insurance premiums {life, home, car, medical)

Clothing, Grocieries, Household Goods

Utilities

Medical Expenses

Other Debts / Expenses (e.g., child support, loans, other)

Assets

This information may be used if your income is above 200% of Federal Poverty Level guidelines to determine whether you may be eligible for discounted care.

Checking Account

Business Ownership

SSI / Disability?

Child Support

Savings Account

Stocks and Bonds

Real Estate (Excluding Primary Residence)

My signature below certifies that everything I have stated on this application is correct and subject to review under audit. I understand that if the information I provide is determined to be false, financial assistance may be denied and I may be responsible to pay for services provided.

Applicant's Signature

Date

Spouse's Signature

Date

I am a

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Financial Assistance Application Form

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Monthly Expenses

Assets

Southern Regional Medical Center

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