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Mizell Memorial Hospital

Financial Assistance Application

Application to apply for financial assistance
Please complete the entire form before submitting.
* Name of Patient:
Please list first, middle & last name
* Date of Birth:
Enter as 00/00/0000 (ex: 04/20/1949
  Any additional patients to be considered on this application?
If so, please list full name and date of birth on each eligible dependent:
* Responsible Party:
  Spouse's Name and Date of Birth:
* Home Address:
* Number of years you have lived at the above address:
* Valid phone number where you can be reached:
Include area code and an active phone number.
* List number of people in household:
* Number of dependent children in household:
* Ages of dependent children:
* If you are seeking financial assistance for services already rendered, list account numbers:
* Type of services rendered: Emergency room
Outpatient surgery
Outpatient diagnostic
Inpatient
Other
  Expected Dates of Services for future services:
* Responsible Party's Employer, Address & Phone number
* Position at employer
* Number of years with employer:
* Wages/Salary Monthly
  Spouse's Employer, Address & Phone Number
  Spouse's position at employer
  Spouse's number of years at employer
  Spouse's wages/salary monthly
REFERENCES
* Name, Address & Phone number
* Name, Address & Phone number
* Nearest Relative, Address & Phone number
  List your bank:
  Current amount in checking: $
  Current amount in savings: $
* Please check if you own, buying or renting home?
* Enter monthly home payment:
* Stock amount?
* Bond amount: $
* CD's amount: $
* IRA's amount: $
* Is any other property owned? yes
no
  If yes to other property owned, list land value amount in $
* Automobile(s) value: $
* Do you have a second mortage on your home or property? yes
no
MONTHLY EXPENSES
* Housing: $
* Food: $
* Furniture: $
* Clothing: $
* Insurance:$
* Support/Alimony: $
* Second Mortage: $
* Land Loan: $
* Car Loan: $
* Charge Cards: $
* Lights: $
* Water: $
* Phone: $
* Gas: $
* Medical Expenses: $
  Other Expenses
Please list description and amount
* TOTAL OF MONTHLY HOUSEHOLD EXPENSES: $
MONTHLY HOUSEHOLD INCOME
* Welfare: $
  Food Stamps: $
* Social Security: $
* Wages/Salary: $
* Support/Alimony: $
* Pension: $
* Total of monthly income: $
* Enter the difference of total monthly income and expense: $
* Enter charge card balances: $
  J.C. Penney: $
  Mastercard:
  Sears: $
  Visa: $
  Other credit card:
  Other credit card: $
Insurance Coverage
  Insurance Group:
  Name of insured:
  Reason for no coverage:
ADDITIONAL INFORMATION:
If there is any other information that you think we should know to help determine your eligibility enter that information here:

STATEMENT: Please read the following statement. You will electronically sign and date this form and that will stand as your signature. I understand that the information which I submit is subject to verification and subject to review by the Federal and State Enforcement agencies and others as required. I certify that the above information is true and correct. The following documents MUST be provided to verify income and family size: 1) ALL sources of income, including paycheck stub, food stamps, social security and SSI. 2) Income Tax Form 3) Medical Expenses 4) Receipts for ALL expenses for 1 month. 5) Copy of last bank statement. *If the supporting documentation is not provided with this application, Financial Assistance will be DENIED.
* Sign & date
Your electronic signature attests to having read and agreeing with the above statement.