Financial Assistance Application

Money For Medical Bills

PO Box 1555
Temple Hills, MD. 20748

moneyformedicalbills@gmail.com

(877) 772-4209
FINANCIAL ASSISTANCE APPLICATION
Dear Financial Applicant,

Thank you for contacting MONEY FOR MEDICAL BILLS. Your inquiry has been received. Per your request we are attaching a financial application to be completed and returned within 10 business days of receipt. In order to be considered for financial assistance you must meet the below criteria, complete, sign and date the application. You will also need to provide a copy of your photo ID, income and expenses.*All items can be uploaded directly into the application*

Services that are excluded from Financial Assistance consideration, include, but are not limited to:

A. Elective cosmetic services

Charity review will be extended to those who qualify based on the following reasons:
(1) The patient is uninsured
(2) Meets Federal Poverty Guidelines
(3) The patient is determined to be unable to pay for services provided
(4) Household Income
(5) All payment efforts have been exhausted
(6) Medical Expenses incurred by unexpected/required Emergency Services

If you have any other questions or concerns regarding the application process please contact us via email at moneyformedicalbills@gmail.com
Date

MonthDayYear
Date
Personal Information
Patient Name*

TitleFirst NameLast Name
Birth Date

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone *
Cell Phone*
E-mail
example@example.com
Social Security #*
Marital Status
Dependent Information
Total # of Dependents
Dependent Name Relationship
Dependent Name Relationship
Dependent Name Relationship
Dependent Name Relationship
Dependent Name Relationship
Do you have additional dependents?

YesNo
Please reference the dates(s) of service that this request affects:
Please reference the dates(s) of service that this request affects:
*Applicant must reapply for future approvals other than dates listed above. Consideration will be based current financial status.*
Employment Information
Patient Employer*
Employer Address*
City/State/Zip Code*
Work Phone*
How long have you worked here?
Spouse Employer
Employer Address
City/State/Zip Code
Work Phone
How long have you worked here?
Income and Expenses
All applications must be accompanied by income and expense verification to include the items from below.

Missing documents may result in a delay in considering your request.

Proof of Income: Please provide the following documents: 2 items required
-Paystubs from the last 3 months
-An official income verification letter from your employer
-Your current taxes and W-2 forms
-If you are receiving assistance from the state, county or district, please provide a ‘letter of support’ from
the organization or agency that provides assistance.
-Unemployment benefits
-Social Security benefit statement

Proof of Expenses: Please provide the following documents:
-Rent receipts from the last 3 months
-3 months of utility bills (2 Vendors in your name)
-3 months transportation (Ie: car payment receipts, Uber/Lyft, Metro pass etc.)
-3 months bank statements
-Copies of current medical bills
File Upload

Cancelof
Monthly Expenses
Rent
Utilities
Transportation
Food
Medical Expenses
Total Expenses
Provider Information
Provider Name
Address
City/State/Zip Code
Phone #
Total Amount
Provider Name
Address
City/State/Zip Code
Phone #
Total Amount
Provider Name
Address
City/State/Zip Code
Phone #
Total Amount
*You may request up to 3 bills to paid. Please note payments will be made based on qualifications and available funds.
*You may apply every 12 months
*You agree to sign authorization of release which will allow MONEY FOR MEDICAL BILLS tonegotiate and or appeal medical bills on your behalf. This will include medical providers and health insurance carriers. This may also include discussing treatment, service, and or coding.
I hereby agree that the information given is true, accurate and complete as of the date of this application submission.

YES
By signing this form, your signature acts as authorization for Money For Medical Bill's to advocate for you to include discussing treatment, coding, and billing for account resolution. *This authorization expires 1 year from date of signature*
Signature

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Date

MonthDayYear
Date
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FINANCIAL ASSISTANCE APPLICATION

Personal Information

Dependent Information

Employment Information

Income and Expenses

Provider Information