Note: This is a reference translation to help you understand a typical form. It is not an official document. Your provider's actual form may differ — always sign the provider's own version.
When you receive this formYou can request this application at any non-profit hospital's billing or patient financial services department. The hospital may also offer it proactively when a large bill is incurred. You do not need to wait to be offered it — ask for it at any time.
What to bring or have readyBring recent pay stubs or your most recent tax return, and any documents that show household size (such as tax filing records listing dependents). If you are unemployed or have no income, ask the hospital what alternative documentation they accept.
Patient and Household Information
English
What this field means
Patient Name
Your legal name, matching the name on your hospital account or any insurance on file.
Date of Birth
Used to identify your hospital account and verify the application matches the patient on file.
Mailing Address
The address where the hospital will mail any determination letters or follow-up communications about your application.
Household Size
The total number of people currently living in your household, including yourself, a spouse, children, and any other dependents. The hospital uses this figure alongside income to determine eligibility.
Income and Employment
English
What this field means
Employment Status
Indicate whether you are currently employed full-time, part-time, self-employed, unemployed, retired, or unable to work. This helps the hospital understand your income sources.
Household Monthly Income (all sources combined)
The total income received by all members of your household in a typical month, from all sources including wages, benefits, and other income. The hospital uses this information to assess your eligibility — no specific dollar figure is set by this form.
Other Income Sources
List any income sources beyond regular wages, such as Social Security, disability benefits, unemployment, child support, alimony, or rental income.
Insurance Status
English
What this field means
Current Insurance Status
Indicate whether you currently have health insurance. Common options include: insured (with insurance name), uninsured (no coverage), or underinsured (coverage does not adequately cover the services or costs).
Reason for Uninsurance or Underinsurance
If you are uninsured or underinsured, briefly explain why — for example, employer does not offer coverage, you are between jobs, coverage was unaffordable, or you recently lost coverage. This context helps the hospital's review.
Supporting Documents Required
English
What this field means
Recent Pay Stubs or Wage Statements
Attach recent pay stubs (typically the last 1–3 months) for all employed members of your household. These verify the income information you reported above.
Most Recent Tax Return
If available, attach a copy of your most recent federal or state tax return. This provides a comprehensive picture of annual household income and may be required if you are self-employed.
Bank Statements (last 2–3 months)
Some hospitals request recent bank statements to supplement income documentation. Check the hospital's specific requirements — this document is not required by all financial assistance programs.
Signature and Certification
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What this field means
Patient / Authorized Representative Signature
Your signature certifies that the information provided in this application is true and complete to the best of your knowledge. Providing false information may disqualify you from assistance.
Date Signed
The date on which you are signing and submitting this application.