|
Check other bills you are receiving: |
[ ]
Health
Associates |
[ ]
Peace Harbor
Hospital |
[ ]
PeaceHealth
Medical Group |
[ ]
Sacred Heart
Medical Center |
|
Please complete all sections of this application and return within 5
days. Thank you.
|
Patient
| Patient
Name: |
Patient's
Date of Birth:
/ / |
Responsible Party ("RP")
| Name: |
Spouse
Name: |
| Street
Address: |
Home
Phone Number: (
) - |
| City,
State, Zip: |
| Date
of Birth:
/ / |
Spouse
Date of Birth:
/ / |
| Social
Security Number:
- - |
Spouse
Social Security Number:
- - |
| Employer: |
Spouse
Employer: |
| How
Long? |
Work
Phone: (
) - |
How
Long? |
Work
Phone: (
) - |
| Occupation |
Spouse
Occupation |
| #
Children/Dependents |
Ages |
# of others in
Household |
| If
over 18, why are they dependent on you?
|
Income and Financial Data
| Responsible
Party |
Spouse |
| Gross
Salary: $ |
Net
Income: $ |
Gross
Salary: $ |
Net
Income: $ |
| Hourly
Wage: $ |
Hrs
Worked per Week: |
Hourly
Wage: $ |
Hrs
Worked per Week: |
|
Monthly Income Other Than
Employment |
| Public
Assistance/Welfare |
$ |
Unemployment
Benefits |
$ |
| Child
Support/Alimony |
$ |
Military
Allotment/Vet Benefits |
$ |
| Social
Security |
$ |
Food
Stamps |
$ |
| Pension(s) |
$ |
Workmen's
Compensation |
$ |
| Dividends/Interest |
$ |
Rental
Income |
$ |
| TOTAL
MONTHLY INCOME FROM ALL SOURCES |
$ |
Assets
| Description |
Market
Value |
Balance
Owed |
| Property/House: |
$ |
$ |
| Automobiles: |
$ |
$ |
| Other
(describe): |
$ |
$ |
| |
$ |
$ |
| Investment
Accounts (Money Market, IRA, CDs, etc.) |
| |
Value:
$ |
| |
Value:
$ |
Monthly Living Expenses
| Home:
|
[
]Rent
Landlord Name and Address:
|
[
]Own
Mortgagor Name and Address: |
Amount
paid |
$ |
| Property
Tax included in monthly payment? [
]Yes [ ]No |
Amount
of tax |
$ |
| Transportation: |
Auto
(gas, oil) |
$ |
Bus,
taxi |
$ |
Total |
$ |
| Miscellaneous: |
Cable |
$ |
Newspaper |
$ |
Total |
$ |
| Utilities: |
Electric:
$ |
Water:
$ |
Gas: $ |
Phone:
$ |
Total |
$ |
| Child/Dependent
Care: |
Total |
$ |
| Clothing: |
Purchase: |
$ |
Laundry: |
$ |
Total |
$ |
| Insurance: |
Life: $ |
Health:
$ |
Auto: $ |
Other:
$ |
Total |
$ |
| Special
Medical Costs (rental equipment, etc.) |
$ |
| Medications: |
$ |
|
TOTAL MONTHLY LIVING
EXPENSES |
$ |
Medical Bills
| Provider |
Current
Balance |
Monthly
Payment |
| |
|
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|
TOTAL |
|
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Other Creditors
| Creditor
Name |
Current
Balance |
Monthly
Payment |
| |
|
|
| |
|
|
| |
|
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| |
|
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| |
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|
TOTAL |
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| If there are additional factors which
would influence your ability to pay, please explain below:
|
|
By signing below, I certify that the information
is true and complete to the best of my knowledge, and give permission to
PeaceHealth to obtain a credit check and verify this information.
Signature:
Date:
|
| Business
Office Use Only: |
| Account
#: |
| Req
Monthly Payment: |
$ |
Qualif
for Adj [ ]Yes [ ] No |
| Amount
Approved: |
$ |
Cost
Center: |
| FPL
Guidelines: |
$ |
|
| Approving
Signature: |
Date:
/ / |
|