PATIENT APPLICATION FOR FINANCIAL ASSISTANCE

ALL INFORMATION MUST BE COMPLETED BY ANSWER OR N/A (not applicable)

Date of Application: _____/_____/______Social Security Number: ______- __ __ - ______

Date of Birth (DOB):_____/_____/______Marital Status: Married SingleDivorced Widowed

______

Last NameFirst Middle

______

Address

______

CityStateZip Code

Phone Number: ______Cell Phone: ______

Email Address: ______

Do you have any type of health insurance? YES Attach a copy of all insurance cards NO

Do you have a NC Medicaid Card? YES Date Issued: ____/____/______

NO Attach a copy of the denial letter

Are you on Social Security Disability with Medicare or Medicaid? YESNO

Are your dependent children on health insurance or Medicaid? YES NO

Parent or Guardian if patient is under 21:______

Patient (or Guardian) Employer: ______

Employer Address: ______

Are you self-employed? YES NOType of Work: ______

Spouse’s Employer: ______

Employer Address: ______

Is your spouse self-employed? YES NOType of Work: ______

Full Name of everyone living in the household, SSN, DOB and Relationship:

1.______

(NAME)(SSN)(DOB)(RELATIONSHIP)

2.______

(NAME)(SSN)(DOB)(RELATIONSHIP)

3.______

(NAME)(SSN)(DOB)(RELATIONSHIP)

4.______

(NAME)(SSN)(DOB)(RELATIONSHIP)

5.______

(NAME)(SSN)(DOB)(RELATIONSHIP)

6.______

(NAME)(SSN)(DOB)(RELATIONSHIP)

7.______

(NAME)(SSN)(DOB)(RELATIONSHIP)

ASSETS

Bank Accounts:Checking…………………………………………….$______(include most recent statement)

Savings……………………………………………….$______(include most recent statement)

Money Market…………………………………..$______(include most recent statement)

401-K…………………………………………………$______(include most recent statement)

403-B…………………………………………………$______(include most recent statement)

Other…………………………………………………$______(include most recent statement)

MONTHLY INCOME

Monthly Gross Pay…………………………..$______(include pay stub)

Spouse’s Monthly Gross Pay..………….$______(include pay stub)

Interest/Dividends……………………………$______

Unemployment Benefits………………….$______

Railroad Retirement……………………….$______

Social Security………………………………….$______

SSI/SSDI………………………………….……….$______

AFDC………………………………………………..$______

Rental Income………………………………….$______

Land Lease/Rental…………………………..$______

Annuities……………………………………….…$______

Civil Service……………………………………..$______

Pensions…………………………………………..$______

Retirement Income………………………….$______

Veteran’s Benefits…………………………..$______

Food Stamps…………………………………..$______

Alimony…………………………………………..$______

Child Support…………………………………..$______

Other______$______

TOTAL MONTHLY INCOME……………..$______

EXTRAORDINARY EXPENSES:

If you have any extraordinary expenses that should be considered, i.e. chemo, dialysis etc., please list below as a monthly expense and attach a copy of statement(s). Attach additional page if needed:

______$______

______$______

ATTACH A COPY OF YOUR LAST YEARS TAX RETURN

PLEASE FILL IN ALL INFORMATION

I certify that this form has been examined by me and that the information given is true and correct to the best of my knowledge.

My spouse and I agree to provide Cornerstone Health Care with any additional information needed to verify statements given in this application and hereby give permission for their agent(s) to obtain such information on our behalf.

I understand that I must apply for any other benefits, i.e. Medicaid, Medicare, and disability etc.,which might pay these accounts before financial assistance can be approved if Medicaid has been denied a copy of the denial letter must be attached.

I understand the above application is for my benefit only and based solely on the disclosure in my application.

I understand that if I give false information a financial assistance approval may be reversed. Further, I understand that Cornerstone Health Care may obtain any credit history of mine or my spouse.

I understand that in order to be considered for financial assistance I must be a legal resident of North Carolina.

I understand that my application will be denied if it is incomplete or I fail to provide required documentation.

I understand approval for financial assistance does not include medications, radiopharmaceuticals, optical or orthotics.

I understand approval of financial assistance does not guarantee future services from any provider.

I understand the information provided is for the undersigned only and does not include any other person listed on this

form.

______

Patient Name (Print)Date

______

Patient or Guardian Signature

______

Spouse’s Name (Print)Date

______

Spouse Signature (if applicable)

FOR OFFICE USE ONLY:DO NOT WRITE IN THIS SPACE

Appropriate Documentation Attached: YES NOAccount Number: ______

Discount % Approved ______Date Approved______

Reviewer Signature: ______

The following documentation must be provided in order to process your Financial Assistance application:

Proof of household income by most recent pay stubs of all employed in the household. If self-employed, provide a copy of most recent federal income tax filed. *

Proof of workers compensation, sick leave, disability compensation, welfare, or social security retirement (SSI not included in income determination), if applicable. If child living with you is under 21 and employed, proof of income may be in the form of a pay stub or certified letter. *

Original of your most recent tax return. *

Original of your Medicaid denial letter, if applicable. *

If you are not married but there are children in common, you must provide entire household income. Any child support tor alimony received must also be included.

If you are still legally married but separated, you must provide legal documentation of separation or spouse’s income. *

If you lost your job within the last three months, you are required to provide a separation letter from your past employer. Additionally, you must provide a letter from your local NC Department of Labor specifying whether or not you are receiving unemployment benefits. If you have no income at this time, provide a signed and notarized letter stating you do not have any income. *

If you have listed any children on your application other than biological or stepchildren, you must provide legal documentation to this effect.

Proof of home address: valid NC driver’s license or ID card, county food stamp letter and one of the following: current utility bill, lease or rent receipts, county property tax assessment, voter registration card. *

You are required to return all information within the next 10 business days. This application is not a guarantee that your account will receive approval or that your account will not follow our collection process. Your accounts will not be placed on hold pending financial assistance consideration.

*We will make copies for you of the original documents when presented to the CBS office listed below.

You will receive an approval or denial letter upon completion of application review.

Please return all information to:

Patient Financial Advocate

Cornerstone Health Care

1701 Westchester Drive, Suite 850

High Point, NC 27262

336-802-2800

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