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.
Responsible party signature:
Spouse Signature:

Comments