Minor Services Financial Assistance Application

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Patient Name*
First Last
SSN*
Patient Date of Birth*
MM
DD
YYYY
Spouse Name
First Last
Spouse SSN
Spouse Date of Birth
MM
DD
YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Number in Household*
Number of Dependents*
Monthly Income (Total Gross for Household)*
INCOME INCLUDES: PATIENT INCOME, SPOUSE INCOME, CHILD SUPPORT/ALIMONY, MONTHLY SOCIAL SECURITY CHECKS, PENSION, UNEMPLOYMENT, SSI, DISABILITY. INCLUDES ANY OTHER INCOME.
Resources
Amount in Checking ($)
Amount in Savings ($)
Stock/Bond/CD Value ($)
403(b)
401(k)
Other
Assets: Total value*
EXCLUDES THE HOME YOU CURRENTLY RESIDE IN; INCLUDES ANY ADDITIONAL PROPERTY, LAND, RENTAL HOMES, ETC.
THIS CERTIFIES THAT I REQUEST TO BE CONSIDERED FOR FINANCIAL ASSISTANCE AT NORTON HEALTHCARE I HEREBY AGREE TO FURNISH NORTON HEALTHCARE WITH THE INFORMATION NECESSARY TO DETERMINE MY ELIGIBILITY FOR ASSISTANCE WITH THE MEDICAL BILLS RESULTING FROM THE SERVICES I HAVE RECEIVED AT THEIR FACILITIES. I UNDERSTAND THAT MY PHYSICIANS AND OTHER HEALTH CARE PROVIDERS MAY HAVE FINANCIAL ASSISTANCE POLICIES THAT COULD ASSIST ME WITH THE MEDICAL BILLS FROM THOSE PROVIDERS. AS SUCH, I AUTHORIZE NORTON HEALTHCARE TO PROVIDE A COPY OF MY APPLICATION TO THOSE PROVIDERS WHO REQUEST IT TO ASSIST THEM IN DETERMINING WHETHER I QUALIFY FOR BENEFITS UNDER THEIR FINANCIAL ASSISTANCE PROGRAMS. I CERTIFY THAT THE INFORMATION PROVIDED BY ME IN THIS APPLICATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT IF I GIVE FALSE INFORMATION OR WITHHOLD INFORMATION IN APPLYING FOR ASSISTANCE, MY APPLICATION WILL BE DENIED AND NORTON HEALTHCARE WILL CONTINUE TO PURSUE COLLECTION OF ANY OUTSTANDING BALANCE DUE. IN THAT INSTANCE, I MAY ALSO BE SUBJECT TO PROSECUTION FOR FRAUD. I AGREE TO NOTIFY NORTON HEALTHCARE OF ANY CHANGES TO THE INFORMATION PROVIDED IN THIS FORM INCLUDING ADDRESS, TELEPHONE NUMBER, AND INCOME.
CONSENT*
By checking here I certify that I have read and understand the above paragraphs, and that I request to be considered for financial assistance for hospital charges at Norton Healthcare.
- Yes
Responsible Party Name*
First Last
Date*
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Minor Services Financial Assistance Application

Minor Services Financial Assistance Application

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