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Ellsworth County Medical Center Logo

Patient Financial Assistance Policy-2

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