Download the Financial Assistance Application

1 Amalia Drive
Buckhannon, WV 26201
Date______________
100%
Denied
(304) 473-2058
Application Approved By:
______________________________
APPLICATION FOR FINANCIAL OBLIGATION DETERMINATION
Date________________ Phone Number____________________ Date of Birth______________________
Patient’s Name ________________________________________ Social Security #___________________
Address _______________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Total Monthly Income ___________________ Number of people living in the home____________________
____________________________________________________________________________
List names, social security numbers and relationships of anyone living in the home
Name
________________________________
________________________________
________________________________
________________________________
Social Security Number
________________________
________________________
________________________
________________________
Relationship
____________________
____________________
____________________
____________________
Income Sources
Social Security $___________
SSI $__________ Alimony$__________ Child Support$___________
Food Stamps $____________
AFDC$_________ Employment$_______ Unemployment$__________
Workers Comp$___________
Pensions$_______ Other $ ____________ Rental Income$__________
___________________________________________________________________________________________
Assets (Do you have any of the following. If yes how much or what is the value.)
Cash on Hand$_____________Credit Union Accounts$_____________ Checking Accounts$___________
Savings Account$___________Stocks or Bonds $ ________________Recreational Vehicles$___________
(such as ATV’s, boats, campers)
Property $_________________Other$_______________________________________________________
(other than your own home)
(please explain)
____________________________________________________________________________
Patient’s Employer ___________________________
Years Employed___________________________
Employer’s Address___________________________
Employer’s Phone Number___________________
Spouse’s Employer___________________________
Years Employed___________________________
Employer’s Address__________________________
Years Employed___________________________
Income includes: Wages before deductions, receipts from self-employment, public assistance payments, Social
Security, Unemployment, Workers Compensation, Strike Benefits, Veterans Benefits, Training Stipends, Alimony, Child
Support, Military Family Allotments, Pensions, Regular Insurance or Annuity payments, Dividends, Interest, Rental
income, Royalties or income from Estates and Trusts.
(OVER)
CREDITORS:
Excluding Automobile Loans- (List below under Auto Payments)
CREDITORS
ADDRESS
(COMPANIES YOU OWE)
(NUMBER,STREET, CITY,ZIP)
EXPENSE ITEMS
ACCOUNT #
PRESENT
BALANCE
MONTHLY PAYMENT
DATE LAST
PAID
MONTHLY
PAYMENT
AMOUNT PAST DUE
RENT
MORTGAGE
ELECTRICITY
GAS OR HEATING
WATER
TELEPHONE
GARBAGE/SEWER
CABLE
LOT RENT
GROCERIES-FAMILY
AUTO PAYMENTS
HOSPITAL/HEALTH INSURANCE
MEDICATIONS
AUTO INSURANCE
LIFE INSURANCE
OTHER (DESCRIBE)
OTHER (DESCRIBE)
I understand that the information I submit is Subject to Verification by St. Joseph’s Hospital and subject to review by Federal and/or State
Enforcement Agencies and others as required. I certify that the above information is true and correct, and I authorize St. Joseph’s Hospital to
verify the same with all of the parties involved. Any false information may result in denial of payment arrangements or assistance, and balances
due may be deemed payable in full immediately. I also hereby grant St. Joseph’s Hospital authority to verify my credit or financial information
with any credit bureau or other appropriate individuals or firms.
Signature_______________________________________________
Date___________________________________