US Medical Forms · 中文

经济援助申请表

⚠ 这是参考翻译，帮助您了解典型表格内容。这不是官方文件。您的医疗提供者的实际表格可能有所不同——请务必签署提供者自己的版本。

When you receive this form 您可以在任何非营利性医院的账单或患者财务服务部门索取此申请表。当产生大额账单时，医院也可能主动提供。您无需等待对方主动提供——可随时索取。

What to bring or have ready 携带近期工资单或最近的纳税申报表，以及任何显示家庭人口的文件（如列有受抚养人的报税记录）。如果您失业或没有收入，请询问医院接受哪些替代文件。

患者及家庭信息 / Patient and Household Information

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Patient Name	患者姓名	Your legal name, matching the name on your hospital account or any insurance on file.	您的法定姓名，与您的医院账户或备案保险上的姓名一致。
Date of Birth	出生日期	Used to identify your hospital account and verify the application matches the patient on file.	用于识别您的医院账户，并核实申请与档案中的患者相符。
Mailing Address	通讯地址	The address where the hospital will mail any determination letters or follow-up communications about your application.	医院将寄送任何关于您申请的决定信函或后续通讯的地址。
Household Size	家庭人口数	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.	目前居住在您家庭中的总人数，包括您本人、配偶、子女和任何其他受抚养人。医院将此数字与收入一起用于确定资格。

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Employment Status	就业状况	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.	说明您目前是全职、兼职、自雇、失业、退休还是无法工作。这有助于医院了解您的收入来源。
Household Monthly Income (all sources combined)	家庭月收入（所有来源合计）	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.	您家庭所有成员在典型月份从所有来源（包括工资、福利和其他收入）收到的总收入。医院使用此信息评估您的资格——此表格不规定具体金额。
Other Income Sources	其他收入来源	List any income sources beyond regular wages, such as Social Security, disability benefits, unemployment, child support, alimony, or rental income.	列出工资以外的任何收入来源，如社会保障、残疾补贴、失业救济、子女抚养费、赡养费或租金收入。

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Current Insurance Status	当前保险状况	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).	说明您目前是否有健康保险。常见选项包括：有保险（附保险名称）、无保险（无保障）或保险不足（保障无法充分覆盖服务或费用）。
Reason for Uninsurance or Underinsurance	未投保或保险不足的原因	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.	如果您没有保险或保险不足，请简要说明原因——例如，雇主不提供保险、您正处于换工作期间、保险费用无法承担或您最近失去了保险。这些背景有助于医院审核。

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Recent Pay Stubs or Wage Statements	近期工资单或工资报表	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.	附上家庭所有就业成员的近期工资单（通常是最近1至3个月）。这些将核实您在上面报告的收入信息。
Most Recent Tax Return	最近的纳税申报表	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.	如果有，请附上您最近联邦或州纳税申报表的副本。这可提供年度家庭收入的全面情况，如果您是自雇人士，可能需要此文件。
Bank Statements (last 2–3 months)	银行对账单（最近2至3个月）	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.	一些医院要求近期银行对账单作为收入文件的补充。请查看医院的具体要求——并非所有经济援助计划都需要此文件。

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Patient / Authorized Representative Signature	患者 / 授权代表签名	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.	您的签名证明您提供的信息在您所知范围内是真实且完整的。提供虚假信息可能导致您失去获得援助的资格。
Date Signed	签署日期	The date on which you are signing and submitting this application.	您签署并提交此申请表的日期。

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Last reviewed: September 2026