Financial Assistance Application

Patient Name*

Account Number*

Application & Supporting Documentation Due Date*

Guarantor Name*

Relationship to Patient*

Social Security Number*

Date*

Gender

Female
Male

Home Phone*

Cell Phone

Work Phone

Marital Status*

Address*

Address City State Zip Country

Own/Rent*

How long have you lived at this address?*

Requesting Assistance for*

Date of Requested Service*

Patient's Employer*

Length of Employment*

Spouse's Employer*

Spouse's Length of Employment*

Do either employer(s) offer health insurance?*

Yes
No

Have you recently lost insurance coverage from a former employer?*

Yes
No

If yes, is it possible you are eligible for COBRA?*

Yes
No

Have you applied for insurance under the Affordable Care Act?*

Yes
No

Cost of Coverage Provided by Employer

Family Coverage Cost

Single Coverage Cost

Are you currently unemployed?*

Yes
No

How long have you been unemployed?*

Do you receive an unemployment check?*

Is your spouse currently unemployed?*

Yes
No

How long has your spouse been unemployed?*

Does your spouse receive an unemployment check*

Name of Bank*

Do you have a checking account at this bank?*

Yes
No

Do you have a savings account at this bank?*

Yes
No

How many people currently live in your household?*

Number of people who are working*

Do you currently receive child support?*

Yes
No

How much child support to you receive per month?*

Do you receive alimony?*

Yes
No

How much alimony to you receive per month?*

Have you ever applied for SSI/Disability?*

Yes
No

When did you last apply for SSI/Disability?*

What was the result for your case?*

Pending
Denied
Approved

Are you represented by an attorney?*

Yes
No

Was this hospital visit accident related?*

Yes
No

Was liability insurance involved?*

Yes
No

Please provide name/phone number/address/policy information of insurance.*

Monthly Income and Expense Summary

NOTE: We must receive copies of bills reported below.

Monthly income received (all sources)*

Expenses

Please list all expenses per month.

Mortgage/Rent*

Credit Cards

Life Insurance

Student/Personal Loans

Car Insurance

House Insurance

Car Payment

Other Expenses

Medical Bills

Total Expenses

$0.00

Authorization

I authorize Cullman Regional Medical Center (CRMC) or its designated agent to obtain a consumer credit report from a consumer reporting agency that collects consumer credit information and issues reports based upon that information. CRMC will use the report in reviewing my account to determine my ability to pay for medical services. I understand that a consumer report contains information relating to my credit standing, credit capacity, character, general reputation, personal characteristics, and standard of living. I understand that by giving consent to a consumer reporting agency, such as Equifax, may provide CRMC with a consumer report about me, in accordance with the Fair Credit Reporting Act. I certify that all of the information provided is true and accurate. I agree that if I am eligible for SSI/Medicaid I will complete the forms within 30 days after I receive approval to have Medicaid reimburse CRMC for services provided.

Authorization Approval*

I agree
Disagree

Name for Authorization Approval*

PERMISSION TO RELEASE INFORMATION TO THE GOOD SAMARITAN HEALTH CLINIC

If you are uninsured, as resident of Cullman County and between the ages of 19 and 65, you may be eligible for healthcare services through Good Samaritan Health Clinic. Much of the paperwork required to qualify for the hospital's Charity Program is very similar to paperwork needed by the GSC. In an effort to speed up the application process the hospital will, with your permission, provide the GSC with copies of the documentation you have provided us. I attest that I am a resident of Cullman County and authorize Cullman Regional Medical Center to release financial information I have provided to CRMC as part of my charity application to the Good Samaritan Health Clinic. Any information not to be provided has been designated as such.

Good Samaritan Release Approval*

I agree
Disagree

Name for Good Samaritan Release Approval*