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We realize that hospital care can be expensive and is often unexpected, so to help meet the needs of low-income uninsured and underinsured people who use our hospitals, Mississippi County Hospital System has a Patient Financial Assistance Application. |
Please submit completed form. Once the form has been received by Mississippi County Hospital System Financial Counselors, you will receive a phone call to set up a date and time for you to come to the facility to begin the application filing. |
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Name of Patient |
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Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number |
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Address |
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Phone |
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City, State, Zip |
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HOUSEHOLD MEMBER: |
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Name |
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Age |
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Employer |
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Relationship to Patient |
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Name |
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Age |
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Employer |
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Relationship to Patient |
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Name |
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Age |
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Employer |
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Relationship to Patient |
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Name |
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Age |
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Employer |
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Relationship to Patient |
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INCOME: List Gross income of Total Household for: Last Twelve Months |
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Wages |
$ |
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Farm/Self Employed |
$ |
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Public Assistance |
$ |
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Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number |
$ |
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Unemployment |
$ |
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Workmens Comp |
$ |
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Strike Benefits |
$ |
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Alimony |
$ |
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Child Support |
$ |
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Military Family Allotments |
$ |
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Pensions |
$ |
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Income from dividends, interest, rent, etc. |
$ |
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Other |
$ |
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EXPENSES: List All Expenses as Requested Below: |
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Medical and Dental
Average Cost |
$ |
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Monthly Payment |
$ |
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Childcare
Average Cost |
$ |
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Monthly Payment |
$ |
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Rent or Mortgage
Average Cost |
$ |
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Monthly Payment |
$ |
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Property Taxes (if not included in mortgage)
Average Cost |
$ |
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Monthly Payment |
$ |
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Telephone
Average Cost |
$ |
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Monthly Payment |
$ |
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Electricity
Average Cost |
$ |
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Monthly Payment |
$ |
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Gas
Average Cost |
$ |
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Monthly Payment |
$ |
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Water
Average Cost |
$ |
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Monthly Payment |
$ |
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Food
Average Cost |
$ |
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Monthly Payment |
$ |
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Other Expenses not listed above: |
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Account 1 |
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Account 2 |
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Account 3 |
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Account 4 |
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Account 5 |
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Account 6 |
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LIST ALL CARS, TRUCKS, BOATS, MOBILE HOMES, CAMPERS, MOTORCYCLES OR OTHER VEHICLES: |
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Make |
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Model |
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Year |
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Monthly Payments |
$ |
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Loan |
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Make |
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Model |
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Year |
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Monthly Payments |
$ |
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Loan |
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Make |
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Model |
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Year |
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Monthly Payments |
$ |
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Loan |
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Make |
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Model |
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Year |
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Monthly Payments |
$ |
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Loan |
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List ALL Household Members Savings:
(including cash on hand, savings account, checking accounts, stocks, bonds, credit union, etc.) |
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Does anyone in your household own any real estate, i.e. house, land, buildings (including the house you live in): |
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If yes, you need to supply information about the value of the property, any amount owed, and how the property is used: |
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Value |
$ |
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Amount Owed: |
$ |
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How Used: |
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Do you have health insurance? |
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If yes, please list |
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Do you have disability income insurance? |
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If yes, please list |
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*I affirm that the above information is true and correct to the best of my knowledge.* I authorize Mississippi County Hospital System to obtain a copy of my credit report if deemed necessary to aid in determining my eligibility for financial assistance. |
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Date |
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Electronic signature of person making request |
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