Financial Assistance Online Form

Please complete the following form.

Financial Assistance Application

Patient Name:
Balance:
Account Number:
Date:

Responsible Party Information

Name of responsible party:
Home Phone:
Home Address:
Home City:
Home State:
Home Zip:
Name of Employer:
Title:
Length of employment:
Employer Address:
Employer Phone:
Gross monthly Wages:
Net Monthly Wages:
Marital Status:
Ages of child dependents:
Names of dependant children:
Number of months they live with you:

Spouse Information

Name:
Name of Employer:
Title:
Length of Employment:
Employer Address:
Employer Phone:
Gross Monthly Wages:
Net Monthly Wages:
Other Income (define):
Other Income (amount):
Other Income Period:

Assets

Cash on hand (include savings and checking):
Loans to Others (Specify):
Amount Loaned To Others:
Stocks / Bonds:

Vehicle 1

Year:
Make:
Model:
Value:

Vehicle 2

Year:
Make:
Model:
Value:

Home/Real Estate

Primary (Home):
Other (Value):
Other (Value):

Other Assets To Itemize - Asset 1

Name:
Value:

Other Assets To Itemize - Asset 2

Name:
Value:

Other Assets To Itemize - Asset 3

Name:
Value:

Other Assets To Itemize - Asset 4

Name:
Value:

Liabilities

Name of Firm Unpaid Balance Monthly Payment
Home Mortgage:
Rent:
Bank Loan 1:
Bank Loan 2:
Finance Company 1:
Finance Company 2:
Credit Union Loans:
Credit Card 1:
Credit Card 2:
Credit Card 3:

Name of Firm Unpaid Balance Monthly Payment Purpose Of Loan
Personal Loan 1:
Personal Loan 2:
Collection Agency 1:
Collection Agency 2:
Collection Agency 3:
Collection Agency 4:
Collection Agency 5:
Collection Agency 6:
Collection Agency 7:

Monthly Expenses

Groceries:
Car Exp. (gas, oil, maint.):
Car Insurance:
Health Insurance:
Life Insurance:
Electricity:
Telephone:
Gas / Propane:
Cable / Satellite TV:
Water / Garbage:
Child Care:
Credit Cards:
Child Support:

Others to Itemize

Pharmacy:
Doctors:
Hospitals / Clinics:

Other Monthly Expense

Expense Name:
Expense Value:

I hereby acknowledge that the information given to Great River Medical Center is true and correct to the best of my knowledge. I hereby authorize Great River Medical Center to verify any or all information given.

By completing and submitting this form you are authorizing Great River Health Systems to receive information related to this form via email communication.

Responsible party signature:
Spouse Signature:

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