Screening Application

Patient Application for Eligibility
Thank you for your interest in becoming a patient at Medical Outreach Ministries.

Please review the following information carefully.

In addition to this completed form, we need copies of several documents to complete your application. You should gather these documents BEFORE you start to complete the online form. You may need to upload or take a picture of these documents as part of your application. You may also bring hard copies of these items to the clinic or submit them via mail or email, if you prefer to fill out a paper application.

1. Identification - Must be a current, picture ID - Driver's License or State Issued ID

2. Social Security Card - If you do not have your Social Security Card, an official Federal or State tax document with your number on it is acceptable.

3. Tax Information

If you do NOT file taxes: Sign Form 4506-T in the online form.

If you file taxes: Income Tax Return - Form 1040, pages 1-2 of your most recent return. (Prior to April 15, previous year's return is acceptable. After April 15, the most recent year's return is required.)

4. Income Information

Must include income information for the entire household.

If you have ZERO income, provide ONE of the following:
- Letter signed by someone who financially assists you. Form will print with your application or contact our office to get a copy.
- Food Stamp Letter
If you have income, provide any that apply to you:
- Pay stubs (3 most recent pay stubs)
- Benefits letter (ex. SSI, unemployment, food stamps, housing voucher, other government benefits) - Letter must be current and list your name and monthly amount.
- Proof of Child Support/Alimony payments
- Most recent bank statement - Must list your name and beginning and ending balance.
PLEASE NOTE: Due to HIPAA rules, you cannot save and return to this form. Make sure you have gathered all the information that you need to complete it.

If you have your documents ready, click "NEXT" to get started!

Application Instructions

First, we need to gather some basic information about you and your household.

Please complete every field that applies to you.

A red * indicates that a field is required.

If you do not receive an email confirmation after submission, your application was not fully processed. Please make sure that you click the green SUBMIT button at the end of the application.
Email to receive your Submission Confirmation

Confirmation EmailConfirm email address

Next, we need to collect information for the Baptist Health Charity Care/Financial Assistance program. Medical Outreach Ministries partners with Baptist's program to provide our patients with access to labwork, imaging, and specialty services.

The next four pages are required for the Baptist Health/Medical Outreach Ministries program.

Today's Date*

MonthDayYear
Social Security #*
Marital Status*

MarriedSingleDivorcedWidowedSeparated
How long have you lived in Alabama?*
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Previous Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Can we text you at your cell number?*
Email address

List all people living in the household. Anyone 18 and over should have an income entered. If none, enter 0.*

	Name	Date of Birth	SSN#	Annual Income
Applicant
Spouse
Dependent
Dependent
Dependent
Dependent
Dependent

Total Annual Household Income

INCOME and ASSETS

Please complete every section that applies to you. Enter "0" if an item does not apply to you.

Documentation must be submitted for every source of income and assets listed (ex. benefits letters, income tax returns, etc.).

Income - Enter numbers only

Enter "0" if a type does not apply to you. Every type of income that you report must have a document to support it.
Monthly Salary*
Spouse's Monthly Salary*
Monthly salary for family members under 18*
Monthly salary for family members over 18*
Select an Income Document to submit:
1040 or W2 preferred. If submitted, pay stubs must be current.
Dividend and Interest*
Rental Income*
Pension Income*
Alimony (income, not payments)*
Social Security Benefits*
VA Benefits*
Income from estates, trusts*
Other*
Source of income listed as "Other" above
TOTAL INCOME PER MONTH
Calculated from information above
Applicant's Employer, if any
Spouse's Employer, if any
Do you file taxes?*

YesNo
Sign here to authorize Medical Outreach Ministries to submit a Form 4506-T to the IRS to confirm that you do not file.*

Clear
Income Documentation

Choose how to submit your documents. Avoid shadows and blurry photos.
Tax Return (1040)*
1040 Tax Return (page 1)*
1040 Tax Return (page 2)*
Tax Return File Upload*

Cancelof
W-2*
W-2*
W-2 (for second job or family member)
W-2 File Upload*

Cancelof
Paystubs*
Paystub 1*
Paystub 2*
Paystub 3*
Paystub 4*
Paystub Upload*

Cancelof
Social Security Benefits Letter*
Social Security Benefits Letter*
Social Security Benefits Letter Upload*

Cancelof
Other Proof of Income*
Dividends/Interest, Rental, Pension, Alimony, VA Benefits, Estates/Trusts, Other
Other Proof of Income
Other Proof of Income
Other Proof of Income Document Upload*

Cancelof
Your answers show that you do not have any monthly income. In order to complete your application, you MUST submit either a Food Stamp Letter or a Zero Income Notarized Letter. Choose one method to document how you are supported. *
Zero Income Notarized Letter - Print this letter and ask a friend or family member who supports you to sign it and have it notarized. If you cannot print, contact the clinic for a copy. ***This MUST be turned in to the clinic to complete your application***
Assets - Enter numbers only

Enter "0" if a type does not apply to you. Every asset you report must have a document to support it.
Home (recent appraised value)*
Checking Account Balance (provide current month's statement)*
Savings Account Balance (provide current month's statement)*
IRA (provide copy of certificate)*
Other Asset*
TOTAL ASSETS
Calculated from information above.
Checking Account(s) - Name of Bank(s), if applicable
Saving Account(s) - Name of Bank(s), if applicable
Asset Documentation

Choose how to submit your documents. Avoid shadows and blurry photos.
Bank Statement*
Checking, savings, etc.
Bank Statement Photo*
Bank Statement Photo
Bank Statement Upload*

Savings, Checking etc.
Cancelof
Asset Document*
Home appraisal, IRA certificate, or other asset documentation
Asset Document Photo*
Asset Document Photo
Asset Document Upload*

Cancelof
Other Types of Assistance - Enter numbers only

Enter "0" if a type does not apply to you. Every type you report must have a document to support it.
Food Stamps/SNAP*
Housing Assistance - HUD*
Housing Assistance - Section 8*
Utilities Assistance*
Help from friends, relatives, or others to cover regular expenses (rent, car, etc.)*
Food Stamps/SNAP*
Food Stamps/SNAP Letter Photo*
Food Stamps/SNAP Letter Upload*

Cancelof
Other Assistance Document*
Other Assistance Document Photo*
Other Assistance Document Upload*

Cancelof
I provide my consent and understand that the information I submit is subject to verification by Baptist Health and subject to review by state and/or federal enforcement agencies, and other entities as required by law. I also understand that Baptist Health reserves the right to ask for additional information.

I certify under the statutes of perjury that the information on these pages is true and correct, and that I do not have the financial means to pay for medical care rendered to the above patient. If my financial situation changes in the upcoming calendar year, I will report these changes to Baptist Health immediately.

*My signature on this application verifies that if I am entitled to any other medical benefits, including, but not limited to, a supplemental insurance policy, I will provide Baptist Health with this information and understand that if I choose not to give any information regarding my supplemental insurance carrier, my application for assistance could be denied, and I will be responsible for the total amount of all outstanding bills at Baptist Health. I read and understand what is not covered by financial assistance and I cannot request a further review/audit of my charges once financial assistance is approved.

*Financial Assistance does not include Medications prescribed for patients to self-administer upon discharge.

I give Baptist Health permission to email me (if email is provided) my approval/denial letter.
Signature of Responsible Party*

Clear
Date*

MonthDayYear
Date

Financial Assistance does not cover the following services:
- Copays
- Reconstructive surgery which is not medically necessary
- Cosmetic surgery
- Breast implants
- Teeth extractions (excluding radiation, transplant patients or extractions due to trauma)
- Weight loss surgery
- Genetic testing that is required for determining treatment will be covered, but all other genetic testing will be charged to the patient.
- Medications prescribed for patients to self-administer upon discharge.
- Durable medical equipment
- Routine Physical Exams
- Services not normally covered by health insurance
These are examples of services not covered under the Financial Assistance Program. This list may not include all exclusions to the program.

Should you have questions regarding your particular plan of care, please feel free to call our office at (334) 747-4270.

We reserve the right to change or update covered or non-covered services without notice.

My signature below verifies that I have read and understand the list and statements stated above.
Signature of Responsible Party*

Clear
Date*

MonthDayYear
Date

Medical Outreach Ministries has received Federal funds to assist in operating its Nutrition and Prescriptions program.

Information regarding annual family income is required to determine participant(s) eligibility for public service activities funded by the City of Montgomery through the US Department of Housing & Urban Development's (HUD) Community Development Block Grant (CDBG) Program. Information provided is subject to verification by the agency providing services, the US Department of HUD, and/or the City of Montgomery.

The next page is a form required by the City of Montgomery for a grant that helps to fund Medical Outreach Ministries.

Please complete and sign.

	$0 up to $17,600	$17,601 up to $29,300	$29,301 up to $46,850
Income Range

	$0 up to $20,100	$20,101 up to $33,450	$33,451 up to $53,550
Income Range

	$0 up to $22,600	$22,601 up to $37,650	$37,651 up to $60,250
Income Range

	$0 up to $25,100	$25,101 up to $41,800	$41,801 up to $66,900
Income Range

	$0 up to $27,150	$27,151 up to $45,150	$45,151 up to $72,300
Income Range

	$0 up to $29,150	$29,151 up to $48,500	$48,501 up to $77,650
Income Range

	$0 up to $31,150	$31,151 up to $51,850	$51,851 up to $83,000
Income Range

	$0 up to $33,150	$33,151 up to $55,200	$55,201 up to $88,350
Income Range

Anything else? Use this area to write any further comments about your income or household that we may need to know to process your application.

Your application is ALMOST finished!

You must hit the GREEN SUBMIT button at the bottom of this page to submit it.

The clinic will contact you if we need any further information or clarification.

You may contact the clinic at 334-281-8008 if you have any questions.

Click PREVIEW PDF below to view, save, or print your application.

Because of HIPAA rules, it will not be available to print or save after you hit Submit.

If you choose to preview the PDF, you must hit "Back to Form" in the top left of the PDF screen to come back to this screen, and then hit the SUBMIT button below.

We look forward to serving you!
Should be Empty:

	Insurance Company	Policy #	Group #
1.
2.
3.

Patient Application for Eligibility

Application for Eligibility

Income - Enter numbers only

Income Documentation

Assets - Enter numbers only

Asset Documentation

Other Types of Assistance - Enter numbers only