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 (Social Security card, alien registry card, birth certificate, baptismal or marriage certificate, passport, visa, employee ID card, etc.)
Last year’s Form 1040 federal income tax return, with all Forms W-2 and/or 1099
Last two weeks of paystubs with year to date totals, or last three 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 you are currently receiving Social Security benefits, a copy of your “benefit amount” letter
Copies of bank statements for checking, savings, certificates of deposit, etc. for the last three months
A copy of a current utility bill, telephone bill, or cable television bill from the residence at which you reside
If 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.
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Personal Information
Personal information of applicant (or parent, if applicant is a minor)
Name
First Name
Middle Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State
Zip Code
Living at this address since
blanks
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Phone Number
Please enter a valid phone number.
Social Security Number
Marital Status
Single
Married
Divorced
Widow
Spouse's Name
Spouse's Social Security Number
Spouse's Date of Birth
-
Month
-
Day
Year
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.
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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)
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Employment and Income Information
Employment information of applicant (or parent, if applicant is a minor)
Employer
Unemployed?
Yes
No
Date of Unemployment
-
Month
-
Day
Year
Date
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Does employer offer health insurance?
Yes
No
Occupation/Position
Date of Hire
-
Month
-
Day
Year
Date
Student
Yes
No
Number of credits this semester
Name of School
Monthly Salary
Gross
Net
Hourly Pay
Hours Worked Weekly
Additional Source(s) of Income (per month)
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
Employment Information of Spouse (if applicable)
Spouse's Employer
Unemployed?
Yes
No
Date of Unemployment
-
Month
-
Day
Year
Date
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Does employer offer health insurance?
Yes
No
Occupation/Position
Date of Hire
-
Month
-
Day
Year
Date
Student?
Yes
No
Name of School
Number of Credits this Semester
Monthly Salary
Gross
Net
Hourly Pay
Hours Worked Weekly
Additional Source(s) of Income (per month)
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
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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
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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.
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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
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Date
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Month
-
Day
Year
Date
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