Financial Assistance Application Patient Name*Account Number*Application & Supporting Documentation Due Date* Guarantor Name*Relationship to Patient*Social Security Number*Date* GenderFemaleMaleHome Phone*Cell PhoneWork PhoneMarital Status*MarriedSingleWidowDivorcedAddress* Address City State Zip AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Own/Rent*How long have you lived at this address?*Requesting Assistance for*Prior Service DateFuture Service DateDate of Requested Service* Patient's Employer*Length of Employment*Spouse's Employer*Spouse's Length of Employment*Do either employer(s) offer health insurance?*YesNoHave you recently lost insurance coverage from a former employer?*YesNoIf yes, is it possible you are eligible for COBRA?*YesNoHave you applied for insurance under the Affordable Care Act?*YesNoCost of Coverage Provided by EmployerFamily Coverage CostSingle Coverage CostAre you currently unemployed?*YesNoHow long have you been unemployed?*Do you receive an unemployment check?*Is your spouse currently unemployed?*YesNoHow 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?*YesNoDo you have a savings account at this bank?*YesNoHow many people currently live in your household?*Number of people who are working*Do you currently receive child support?*YesNoHow much child support to you receive per month?*Do you receive alimony?*YesNoHow much alimony to you receive per month?*Have you ever applied for SSI/Disability?*YesNoWhen did you last apply for SSI/Disability?* What was the result for your case?*PendingDeniedApprovedAre you represented by an attorney?*YesNoWas this hospital visit accident related?*YesNoWas liability insurance involved?*YesNoPlease provide name/phone number/address/policy information of insurance.*Monthly Income and Expense SummaryNOTE: We must receive copies of bills reported below.Monthly income received (all sources)*ExpensesPlease 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 agreeDisagreeName for Authorization Approval*PERMISSION TO RELEASE INFORMATION TO THE GOOD SAMARITAN HEALTH CLINICIf 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 agreeDisagreeName for Good Samaritan Release Approval* This iframe contains the logic required to handle Ajax powered Gravity Forms.