Financial Assistance Applications vary by facility. However, most of them contain the following information, so be prepared to provide it if you are planning to apply for any form of financial assistance.

Patient information

• Patient name
• Account number
• Insurance coverage (yes or no)
• Patient Social Security number
• Date of service
• Guarantor name
  
• Guarantor Social Security number
  
• Guarantor address
  
• Marital status
  
• Employed (yes or no)
  
• How long?
  
• Employer name and address
  
• Gross monthly earnings (total salary before deductions for taxes, social security, etc.)
  
• Net monthly earnings (total salary after deductions for taxes, social security, etc.)
  
• Spouse name
  
• Spouse social security number
  
• Spouse employer name and address
  
• How long?
  
• Spouse gross monthly earnings (total salary before deductions for taxes, social security, etc.)
  
• Spouse net monthly earnings (total salary after deductions for taxes, social security, etc.)
  
• Family size
  
• List relationship of members in family and their ages

List what your resources are worth (a dollar amount):

• Other income (i.e., rental property)
  
• Cash
  
• Savings account
  
• Checking account
  
• Other
  
• Additional auto value and make and model (for one vehicle)
  Total

List medical debts in a dollar amount:

• Hospital
• Physician
  
• Pharmacy
  
• Other
  Total

Also describe any other means you have for meeting day-to-day living expenses, or situations that you believe are relevant to the approval of your financial assistance application.