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Online Financial Assistance Application

PATIENT AND FAMILY INFORMATION
Patient Name: *
SSN: *
Month/Day of Birth: *
Mailing Address: *
City, state, zip: * ,
Telephone #: *
Spouse/Guarantor Name:
SSN:
Month/Day of Birth:
Mailing Address:
City, state, zip:
Telephone #:
Dependents (If Over 19, copy of tax return or full time status is required)
Dependent 1:
Dependent 1 Age:
Dependent 1 DOB:
Dependent 1 SSN:
Dependent 2:
Dependent 2 Age:
Dependent 2 DOB:
Dependent 2 SSN:
Dependent 3:
Dependent 3 Age:
Dependent 3 DOB:
Dependent 3 SSN:
Dependent 4:
Dependent 4 Age:
Dependent 4 DOB:
Dependent 4 SSN:
EMPLOYMENT INFORMATION
Patient Employer:
Hourly Wage:$
Hours/Week:
Spouse/Guarantor Employer:
Hourly Wage:$
Hours/Week:
TOTAL OTHER INCOME
Social Security:$
Pensions:$
Suplemental Security Income: (SSI):$
Other (Interest, Rental, Alimony, etc):$
Worker's Compensation:$
Worker's Compensation:$
Food Stamps: (Not counted)$
COUNTABLE ASSETS/RESOURCES
Bank Accounts - Name of Bank:
Checking:$
Savings:$
CD:$
Credit Union - Name:
Checking:$
Savings:$
CD:$
OTHER ASSETS
Investments:$
Money Market Accounts:$
Savings Bonds:$
Other:$
HOUSEHOLD EXPENSES
Rent/Mortgage:$
Loan/Lease Payment (1 Vehicle):$
Insurance Premiums:$
Telephone (1 Landline or Cell Phone):$
Trash:$
Electricity:$
Water:$
Sewer:$
Natural Gas:$
I hereby state that the above information is true and correct to the best of my knowledge. By signing this document, I agree to notify Pikeville Medical Center of any changes in my financial position.
Patient's Signature*
YOU MUST CLICK THE BOX BELOW. IF YOU FAIL TO DO SO, ALL THE DATA YOU HAVE ENTERED MAY BE LOST.

 

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PATIENT AND FAMILY INFORMATION
Patient Name: * SSN: * DOB: *
Mailing Address: *City, State Zip: *
Telephone #: *
Spouse/Guarantor Name: SSN: DOB:
Mailing Address:City, State Zip:
Telephone #:
Dependents (If Over 19, copy of tax return or full time status is required)
Dependent 1: SSN: Age: DOB:
Dependent 2: SSN: Age: DOB:
Dependent 3: SSN: Age: DOB:
Dependent 4: SSN: Age: DOB:
EMPLOYMENT INFORMATION
Patient Employer:Hourly Wage: $Hours/Week:
Spouse/Guarantor Employer: Hourly Wage: $ Hours/Week:
TOTAL OTHER INCOME
Social Security:$Worker's Compensation: $
Pensions:$Unemployment: $
Suplemental Security Income: (SSI):$ Food Stamps: (Not counted) $
Other (Interest, Rental, Alimony, etc):$
Total Income $
COUNTABLE ASSETS/RESOURCES
Bank Accounts - Name of Bank:
Checking: $Savings: $CD: $
Credit Union - Name:
Checking: $Savings: $CD: $
Investments:$ Money Market Accounts: $
Savings Bonds:$Other:$
HOUSEHOLD EXPENSES
Rent/Mortgage:$Electricity:$
Loan/Lease Payment (1 Vehicle):$Water: $
Insurance Premiums:$Sewer:$
Telephone (1 Landline or Cell Phone):$Natural Gas: $
Trash:$
I hereby state that the above information is true and correct to the best of my knowledge. By signing this document, I agree to notify Pikeville Medical Center of any changes in my financial position.
Patient's Signature*
YOU MUST CLICK THE BOX BELOW. IF YOU FAIL TO DO SO, ALL THE DATA YOU HAVE ENTERED MAY BE LOST.

 

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