Application for Determination of Eligibility for Financial Assistance

Application for Determination of Eligibility for Financial Assistance

Memorial Hospital and affiliates, PO Box 160, Carthage, IL 62321, (217) 357-6591
Important: YOU MAY BE ABLE TO RECEIVE FREE OR DISCOUNTED CARE: Completing this application will help Memorial Hospital determine if you can receive free or discounted services or other public programs that can help pay for your healthcare. Please submit this application to the hospital Patient Account Department.

IF YOU ARE UNINSURED, A SOCIAL SECURITY NUMBER IS NOT REQUIRED TO QUALIFY FOR FREE OR DISCOUNTED CARE. However, a Social Security Number is required for some public programs, including Medicaid. Providing a Social Security Number is not required but will help the hospital determine whether you qualify for any public programs.
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Employer*
Social Security Number*
Preferred language*

EnglishSpanishOther
Other language preferred
Family members or residents of current Household
Self*
Family member or resident 2
Family members or residents 3
Family members or resident 4
Family members or resident 5
Family members or resident 6
Family members or resident 7
Family members or resident 8
Patients may be eligible for financial assistance as presumptive eligibility without further evaluation. Please answer the questions below to help determine if presumptive eligibility is possible.
Was the patient involved in an accident?*

YesNo
Is the patient a victim of crime and receiving treatment for this crime today?*

YesNo
Does the patient receive any type of State or Federal Assistance such as food stamps, free lunches, WIC program, energy assistance, etc.?*

YesNo
If yes which one
(Please provide us with documentation from that authority verifying your assistance in that program.)

Cancelof
Please provide copies of one or more of the following documents, if available, with your application for income verification.

Most recent W-2, last three months of payroll/unemployment check stubs, 1099-R, SSA-1099, Social Security letter, disability income, self-employment income/expenses, and/or any other household income. Include anyone in the household that is related to income.

Required for processing: Most recent tax return.
File Upload

Cancelof
Please review and sign

I acknowledge that I have made a good-faith effort to provide all information requested in the application to assist the hospital in determining whether I am eligible for financial assistance. I certify that the information in this application is true and correct to the best of my knowledge. I will apply for any state, federal, or local assistance for which I may be eligible to help pay for this hospital bill.
I understand that the information provided may be verified by the hospital, and I authorize the hospital to contact third parties to verify the accuracy of the information in this application. I understand that if I knowingly provide untrue information in this application, I will be ineligible for financial assistance, any financial assistance granted to me may be reversed, and I will be responsible for the payment of the hospital bill. Signature*

Powered by Jotform SignClear
Immigrant Entrance Information:
Date of entry to the U.S.

MonthDayYear
Date
First date of employment in the U.S.

MonthDayYear
Date
Should be Empty:

Application for Determination of Eligibility for Financial Assistance

Family members or residents of current Household

Immigrant Entrance Information: