When you receive this formこの申請書は、非営利病院の請求部門または患者財務サービス部門でいつでも請求できます。大きな請求が発生した際に病院から自発的に提供される場合もあります。提案されるのを待つ必要はありません。いつでも請求してください。
What to bring or have ready最近の給与明細または直近の確定申告書と、世帯規模を示す書類（扶養家族が記載された確定申告記録など）を持参してください。失業中または収入がない場合は、病院が受け付ける代替書類を確認してください。
患者および世帯情報 / Patient and Household Information
English
日本語
English — Help
日本語 — Help
Patient Name
患者氏名
Your legal name, matching the name on your hospital account or any insurance on file.
病院アカウントまたは登録保険に記載されている名前と一致する法的な氏名。
Date of Birth
生年月日
Used to identify your hospital account and verify the application matches the patient on file.
病院アカウントを特定し、申請書がファイル上の患者と一致することを確認するために使用されます。
Mailing Address
郵送先住所
The address where the hospital will mail any determination letters or follow-up communications about your application.
病院が申請に関する決定通知や後続連絡を郵送するための住所。
Household Size
世帯人数
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.
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.
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.
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).
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.
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.
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.
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.
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.