Online Application "*" indicates required fields FacebookThis field is for validation purposes and should be left unchanged.Welcome to your Community Hospital online financial assistance application! In order to process your application, we need supporting documents to verify your financial situation. Required documents include any of the following that apply to your household: Paycheck Stubs Recent Tax Return W-2s Social Security Benefit Letter Letter From an Employer Current Bank Statement for Checking and Savings Accounts Current Medical Bills Owed to Other Providers If we recieve an incomplete application a letter will be sent identifying and requesting the missing information and if the additional information is not received within 30 days the application will be closed. Please get an electronic copy or pictures of your documents ready before starting your application. Applicant Name* First Last Date of Birth*Social Security NumberAddress* Street Address City State Zip Code Phone Number*Spouse/Significant Other Name (If Applicable) First Last Spouse/Significant Other Social Security NumberSpouse/Significant Other Date of Birth*Spouse/Significant Other Phone Number How many Dependents are in the home?*Please enter a number from 0 to 7.Dependent 1 – Name* First Last Dependent 1 – Date of Birth*Dependent 1 – Relationship to Applicant*Dependent 2 – Name* First Last Dependent 2 – Date of Birth*Dependent 2 – Relationship to Applicant*Dependent 3 – Name* First Last Dependent 3 – Date of Birth*Dependent 3 – Relationship to Applicant*Dependent 4 – Name* First Last Dependent 4 – Date of Birth*Dependent 4 – Relationship to Applicant*Dependent 5 – Name* First Last Dependent 5 – Date of Birth*Dependent 5 – Relationship to Applicant*Dependent 6 – Name* First Last Dependent 6 – Date of Birth*Dependent 6 – Relationship to Applicant*Dependent 7 – Name* First Last Dependent 7 – Date of Birth*Dependent 7 – Relationship to Applicant* Income Information Applicant's Employer Name (If Applicable)Employer Address Street Address City State Zip Code Applicant's Employer Phone NumberMonthly Gross Employment Income (If none, enter "0")*Do you recieve any Other income?*(Other Income examples include: SSI, Child Support, Workman’s Comp., Unemployment, Pension, Rent, Alimony, etc.) Yes No Type of Other IncomeSSI, Child Support, Workman’s Comp., Unemployment, Pension, Rent, Alimony, etc.What is the Applicant's Other Monthly Gross Income (Before Taxes)?*Spouse/Significant Other's Employer Name (If Applicable)Employer Address Street Address City State Zip Code Spouse/Significant Other's Employer Phone NumberWhat is the Spouse/Significant Other's Monthly Gross Employment Income (If none, enter "0")*Does your Spouse/Significant Other recieve any other income?(Other Income examples include: SSI, Child Support, Workman’s Comp., Unemployment, Pension, Rent, Alimony, etc.) Yes No Type of Other IncomeSSI, Child Support, Workman’s Comp., Unemployment, Pension, Rent, Alimony, etc.What is the Spouse/Significant Other's Other Monthly Gross Income (Before Taxes)?*If you do not have monthly income, please explain how you take care of your monthly expenses. Financial Information Do you use a bank for financial transactions? Yes No Checking Balance*Savings Balance*HSA/FSA Balance*If no, how do you handle your financial transactions? (i.e. prepaid card, cash, etc.) Do you own or rent your home? Own Rent Primary Residence – ValuePrimary Residence – Mortgage Balance DueRent Amount*Do You Own a Second Residence? Yes No Second Residence – ValueSecond Residence – Mortgage Balance DueDo you own any vehicles? Yes No Vehicle 1 – MakeVehicle 1 – YearVehicle 1 – ValueVehicle 1 – Balance DueDo you own a second vehicle? Yes No Vehicle 2 – MakeVehicle 2 – YearVehicle 2 – ValueVehicle 2 – Balance DueDo you own a third vehicle? Yes No Vehicle 3 – MakeVehicle 3 – YearVehicle 3 – ValueVehicle 3 – Balance DueDo you own other assets including: artwork, jewelry, recreational vehicles, campers, etc.? Yes No Asset 1 – DescriptionAsset 1 – ValueAsset 1 – Balance DueDo you have another asset to list? Yes No Asset 2 – DescriptionAsset 2 – ValueAsset 2 – Balance Due Liabilities & Other Expenses Do you have any liabilities/debts? Yes No Liability 1 – Payment To:Liability 1 – Payment Amount:Liability 1 – Balance Due:Do you have another liability/debt to list? Yes No Liability 2 – Payment To:Liability 2 – Payment Amount:Liability 2 – Balance Due:Do you have another liability/debt to list? Yes No Liability 3 – Payment To:Liability 3 – Payment Amount:Liability 3 – Balance Due:Do you have another liability/debt to list? Yes No Liability 4 – Payment To:Liability 4 – Payment Amount:Liability 4 – Balance Due:Do you have another liability/debt to list? Yes No Liability 5 – Payment To:Liability 5 – Payment Amount:Liability 5 – Balance Due:Do you have other medical bills not owed to Community Hospital? Yes No Medical Bill 1 – ProviderMedical Bill 1 – Balance DueDo you have another medical bill to list? Yes No Medical Bill 2 – ProviderMedical Bill 2 – Balance DueDo you have another medical bill to list? Yes No Medical Bill 3 – ProviderMedical Bill 3 – Balance DueDo you have another medical bill to list? Yes No Medical Bill 4 – ProviderMedical Bill 4 – Balance DueDo you have another medical bill to list? Yes No Medical Bill 5 – ProviderMedical Bill 5 – Balance DueDo you have another medical bill to list? Yes No Medical Bill 6 – ProviderMedical Bill 6 – Balance DueDo you have another medical bill to list? Yes No Medical Bill 7 – ProviderMedical Bill 7 – Balance DueIs there any additional information or explanation you would like to provide? Do you participate in a Christian ministry cost sharing health plan?* Yes No Did you have health insurance at the time of service?* Yes No Insurance Company NameInsurance Company Phone NumberInsurance Group NumberInsurance Member IDAre these services a result of a motor vehicle accident?* Yes No Uploading Documents This section is for attaching the documents we need to fully process your application and verify the information you provided. Please include copies of all of the following that apply to your household. Paycheck StubsPlease upload paycheck stubs for all income earners, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Verification of Income On All Amounts ListedPlease upload verification of income on all amounts listed, if applicable. (i.e. W-2s, social security letter or letter from an employer, alimony/child support, unemployment, retirement/pension) Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Tax ReturnPlease upload your tax returns from last year, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Bank Statements for Checking and Savings Accounts*Please upload your most recent bank statements from your checking and savings accounts, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Current Medical Expense BillsPlease upload your current medical expense statements showing any balance due, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Medical Insurance and/or Medicaid Card – Front & BackPlease attach pictures or copies of the front and back of your medical insurance or Medicaid card effective at the time of service, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. This field is hidden when viewing the formTotal Family Income 3 months prior to the date of service?This field is hidden when viewing the formTotal Family Income 12 months prior to the date of service?This field is hidden when viewing the formFamily AdditionalsThis field is hidden when viewing the formTotal Family SizeThis field is hidden when viewing the formFamily Additional Total 5680This field is hidden when viewing the formYearly Rate 15960This field is hidden when viewing the formTotal 12 Month Income Div by 12This field is hidden when viewing the formCalculated % FPL 12 MonthsSignature*I certify the following information is true and accurate to the best of my knowledge. Further, I will make application for any other assistance which may be available for payment of my hospital charges (Medicaid, Insurance, etc.), and I will take any action reasonably necessary to obtain such assistance and will assign or pay to the hospital the amount recovered for such charges. I understand the information given is to be used to ascertain my ability to pay for the services provided by Community Hospital. I hereby grant permission to Community Hospital to investigate the information contained herein.Spouse/Significant Other Signature (if applicable) Are You Ready to Submit Your Application?* No I’m Ready On a scale from 1-5, with 1 being HARD and 5 being EASY, how was your experience applying for Financial Assistance online?Please enter a number from 1 to 5.Great! Please do not close your browser or leave this page until you see the confirmation page.
