GVH Financial Assistance Application

Gunnison Valley Health Financial Assistance Application

COMPLETING THIS FORM IS NOT A GUARANTEE OF ELIGIBILITY. If you do not complete this application packet or if you return it without the requested supporting documentation, we may be unable to determine whether you qualify for our Financial Assistance Program. In that case, you will be responsible for the full balance due on your account. If you need help in completing this form or gathering the supporting materials, please contact the Financial Counselor at 970-642-4790.
To determine if you qualify for our Financial Assistance Program, please return the following supporting documentation with this completed packet:

A copy of a photo ID (state driver’s license/state ID) or other identification documents (employee ID card, etc.)A copy of the most recent and active health insurance cards for all family members applying in the household.Last year’s Form 1040 federal income tax return, with all Forms W-2 and/or 1099Last two weeks of paystubs with year to date totals, or last two months of paystubs without year to date totals (if paid in cash without paystubs, provide written verification from employer)Proof of income from all other sources such as unemployment compensation, disability income, rental income, pensions, annuities, interest payments, wage and earning statement from Social Security office. - If self-employed – proof of income for the last two months from bank statements including deposits and withdrawals, ledger, profit and loss statements, or invoices and receiptsIf you are currently receiving Social Security benefits, a copy of your “benefit amount” letterProof of residency such as a copy of a current utility bill, telephone bill, or cable television bill which includes your name, physical address, and service addressIf you are a student, a list of the current semester’s credits/classes and a copy of your student ID
Please upload all required supporting documentation listed above.

Cancelof

Personal Information

Personal information of applicant (or parent, if applicant is a minor)
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
Living at this address since blanks.
Phone Number
Please enter a valid phone number.
Social Security Number
Marital Status

SingleMarriedDivorcedWidow
Spouse's Name
Spouse's Social Security Number
Spouse's Date of Birth

MonthDayYear
Date

List family members (including parents, patient, and natural or adoptive siblings) living at above address.

	Family Member's Name	Date of Birth	Relationship to Patient
1.
2.
3.
4.
5.
6.
7.
8.

Insurance Information

	APPLICANT (OR PARENT, IF APPLICANT IS A MINOR)	APPLICANT’S SPOUSE
Do you have health insurance? (Y/N)
If yes, name of health insurance plan
Medicare? (Y/N)
Medicare Part D? (Y/N)
Medicare Supplement? (Y/N)
Medicaid? (Y/N)
Veteran’s Benefits? (Y/N)
Previously had Medicaid? (Y/N) If yes, Medicaid number.

	Monthly Salary
Gross
Net

	Amount
Other Wages
Interest/Dividends
Rental Income
Food Stamps
Alimony
Child Support
Pension/Retirement
Worker's Compensation
Unemployment
Farm Income
Self-Employment
SSI/Social Security
Veteran's Benefits
Other

	Monthly Salary
Gross
Net

	Amount
Other Wages
Interest/Dividends
Rental Income
Food Stamps
Alimony
Child Support
Pension/Retirement
Worker's Compensation
Unemployment
Farm Income
Self-Employment
SSI/Social Security
Veteran's Benefits
Other

	Amount
Other Wages
Interest/Dividends
Rental Income
Food Stamps
Alimony
Child Support
Pension/Retirement
Worker's Compensation
Unemployment
Farm Income
Self-Employment
SSI/Social Security
Veteran's Benefits
Other

Hospital Discount Care Additional Information
What is your preferred method of contact? Phone or Email
Are you experiencing homelessness? Y/N
Are you a resident of, or currently living in Colorado?   Y/N
Are any applicants US citizens?   Y/N
Are any applications Legal permanent Residents (have a Green Card)?   Y/N   If yes, how long?   Months / Years
Are any applicants here on a Visa? (Y/N)   Y/N
If yes, what kind of Visa and what are the dates?   Kind of Visa   Dates
Do you have refugee status (documented by the government)?   Y/N
Are you or is anyone in your household pregnant?   Y/N
Is anyone in your household under 19 years old?   Y/N
Do you have a disability?   Y/N
Do you receive federal disability income?   Y/N
Are you getting help from the Colorado Indigent Care Program?   Y/N
Have you ever received a Medicaid denial letter?   Y/N
Have you ever received a CHP+ denial letter?   Y/N

Monthly Expense Information

Indicate monthly amounts paid or owed on items below.

Rent/Mortgage


Landlord Name
Landlord Phone
Mortgage Lender
Mortgage Amount

Loans


Auto Loans
Personal Loans
Student Loans

Other Obligations


Child Care
Child Support
Alimony
Other

Household Bills


Heat/Utilities
Phone /Cell Phone
Cable TV/Internet
Homeowner's Insurance
Auto Insurance
Health, Dental, Vision Insurance
Life or Disability Insurance
Other Insurance
Medical Bills (hospital/clinic)

Credit Cards


Credit Card
Credit Card
Credit Card

Total Monthly Expenses
Assets

Indicate current fair market value of any of the following

Bank Accounts


Name of Bank
Savings
Checking

Vehicles Owned

	Year/Make	Model	Value
First
Second
Third

Real Estate Owned


Value
Street Address
City, State and Zip

List Other Assets

	Asset	Value
1.
2.
3.
4.

Certification

I certify that the information I have provided in this application and the required supporting documentation is true and correct to the best of my knowledge. I will apply for any federal, state or local assistance for which I may be eligible to help pay for my medical care. I understand that the information provided may be verified by Gunnison Valley Health, and I authorize Gunnison Valley Health to contact third parties to verify the accuracy of the information I have provided. I understand that, if I knowingly provide inaccurate or incomplete information in this application, I may be ineligible for financial assistance, any financial assistance granted to me may be reversed, and I will be responsible for the payment of my medical bills.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Gunnison Valley Health Financial Assistance Application

Personal Information

Insurance Information

Employment and Income Information

Employment Information of Spouse (if applicable)

Hospital Discount Care Additional Information

Monthly Expense Information

Assets

Certification