|
|
Please submit this online form or if preferred, print and return to the hospital admission desk at Ellsworth County Medical Center, 1604 Aylward, P.O. Box 87, Ellsworth, KS 67439; or by fax to 785-472-4491. |
|
Section I: Demographics: |
* |
Patient Name |
|
* |
Last 4 Digits of SSN Last 4 Digits of SSN |
|
* |
Account # |
|
* |
Guarantor's Name |
|
* |
Address |
|
* |
City, State, Zip |
|
* |
DOB |
|
* |
Gender |
|
* |
Marital Status |
|
* |
Home Phone |
|
* |
Cell Phone |
|
* |
Work Phone |
|
* |
Are you a US Citizen? |
|
* |
Legal Permanent Resident? |
|
* |
What country do you reside? |
|
|
Section II: Current Income,Expenses, & Banking Information: |
|
A. Gross Income (before deductions) |
* |
Patient Provide monthly income. |
|
* |
Spouse/Co-Applicant Provide monthly income. |
|
|
B. Net Income (after deductions) |
* |
Patient Provide monthly income. |
|
* |
Spouse/Co-Applicant Provide monthly income. |
|
|
C. Income from Business (if self-employed) |
* |
Patient Provide monthly income. |
|
* |
Spouse/Co-Applicant Provide monthly income. |
|
|
D. Social Security/SSI |
* |
Patient Provide monthly income. |
|
* |
Spouse/Co-Applicant Provide monthly income. |
|
|
E. Retirement |
* |
Patient Provide monthly income. |
|
* |
Spouse/Co-Applicant Provide monthly income. |
|
|
F. Alimony or Child Support |
* |
Patient Provide monthly income. |
|
* |
Spouse/Co-Applicant Provide monthly income. |
|
|
G. Interest and Dividends |
* |
Patient Provide monthly income. |
|
* |
Spouse/Co-Applicant Provide monthly income. |
|
* |
Checking Acct Balance |
|
* |
Savings Acct Balance |
|
* |
CDs/Stocks/Bonds/Mutual Funds |
|
* |
Retirement/401k/IRA |
|
* |
Safe Deposit Box |
|
* |
Rental Property |
|
* |
Auto/RV/Trailer/Boat/ATV |
|
* |
Livestock/Land |
|
* |
Whole Term Life Insurance |
|
* |
Burial Policy |
|
* |
Secondary Residence |
|
* |
Real Estate |
|
* |
Promissory Note |
|
* |
Personal Injury Claims |
|
* |
Do you have other banks accounts? |
|
|
Section III: Family Status: List household members by legal name. Proof of income may be required. |
|
Name |
|
|
DOB |
|
|
Age |
|
|
Last 4 Digits of SSN Last 4 Digits of SSN |
|
|
Relationship |
|
|
Gross Income |
|
|
|
|
Name |
|
|
DOB |
|
|
Age |
|
|
Last 4 Digits of SSN Last 4 Digits of SSN |
|
|
Relationship |
|
|
Gross Income |
|
|
|
|
Name |
|
|
DOB |
|
|
Age |
|
|
Last 4 Digits of SSN Last 4 Digits of SSN |
|
|
Relationship |
|
|
Gross Income |
|
|
|
|
Name |
|
|
DOB |
|
|
Age |
|
|
Last 4 Digits of SSN Last 4 Digits of SSN |
|
|
Relationship |
|
|
Gross Income |
|
|
|
|
Name |
|
|
DOB |
|
|
Age |
|
|
Last 4 Digits of SSN Last 4 Digits of SSN |
|
|
Relationship |
|
|
Gross Income |
|
|
|
|
Name |
|
|
DOB |
|
|
Age |
|
|
Last 4 Digits of SSN Last 4 Digits of SSN |
|
|
Relationship |
|
|
Gross Income |
|
|
|
|
Name |
|
|
DOB |
|
|
Age |
|
|
Last 4 Digits of SSN Last 4 Digits of SSN |
|
|
Relationship |
|
|
Gross Income |
|
* |
Is anyone in the household pregnant? |
|
|
Who? |
|
|
Relationship |
|
|
Section IV: Employment Information: |
|
Current Employer |
|
|
If not working at this time, when and where did you last work? |
|
|
Section V: Information Obtained From: |
* |
Information obtained from |
|
* |
Relationship to patient |
|
|
Section VI: Signature I would like to apply for financial assistance through Ellsworth County Medical Center (ECMC). I understand that it is the
expectation of ECMC that the patients use all of the available financial resources to pay their medical bills before financial
assistance will be granted.
The information I have provided above is true and complete. By signing this form, I agree to allow ECMC to check employment
and credit history for the purpose of determining my eligibility for financial assistance. I also agree and
facilities to release information concerning my financial status to ECMC for the purpose of determining my eligibility for
financial assistance. I understand that I may be required to provide proof of the information I am providing. If this information is
found to be false or misleading, I understand my application will be denied. |
* |
Applicant’s signature |
|
* |
Date |
|
|
Co-Applicant’s Signature |
|
|
Date |
|
|