Financial Assistance Program Application

Financial Assistance Program Application
If you are underinsured and meet specific presumptive eligibility criteria, you are not required to complete this application.

HomelessnessDeceased with no estateMental incapacitation with no one to act on patient’s behalfMedicaid eligibility, but not date of serviceWomen, Infants and Children Nutrition Program (WIC)Supplemental Nutrition Assistance Program (SNAP)Iowa Free Lunch & Breakfast Program
APPLICANT INFORMATION:
Applicant Name: (First, Middle, Last)
Social Security #:
Date of Birth:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone #:
Additional Phone #:
Email
example@example.com
Employment Status:

EmployedSelf-EmployedRetiredDisabledUnemployed
If unemployed - last date worked

MonthDayYear
Date
Employer Name: (if applicable)
Employer Address:

Street Address

CityState / Province

Postal / Zip Code
Name of Health Insurance plan offered by employer (including COBRA)
If your employer does not provide health insurance, check this box.

Health insurance not provided
HOUSEHOLD INFORMATION:

Beginning with yourself, list all persons living in your home.

REAL ESTATE INFORMATION
What is the status of your primary residence?

Rent HomePurchasing HomeOwn HomeHomelessOther
Do you own other real estate?

YesNo
If yes, where?
Value
FINANCIAL RESOURCES/INCOME
Bank Name
Checking Balance
Savings Balance
Stocks/Bonds/CDs
Life Insurance Value

Source:

If your financial assistance application shows no income at all, please describe how you provide for your every day living expenses, such as housing, food, clothing, etc.
MEDICAL RESOURCES
Do you have health insurance?

YesNo
If yes, is insurance obtained through your employer?

YesNo
If no, does your employer offer health insurance?

YesNo
Name of Insurance Company
Address
Policy Holder Name
Policy Number
If you do not have insurance, have you applied for Medicaid? (We may require that you do so.)

Yes, awaiting approvalYes, not eligibleNo
If you have not applied, check the items below that apply.

You are 19 years or youngerYou take medication to control diabetes, high blood pressure, or seizuresYou are 65 years or olderYou are disabled as determined by the Social Security AdministrationYou are blindYou have children under the age of 19 living with youYou are pregnant
Please submit most recent filed tax returns and documentation of income received for the past three months. Please do not send original documents as items submitted with your application will not be returned to you.
File Upload

Cancelof
SIGNATURE
I certify that the information given on this application and any attached supporting document are accurate and complete to the best of my knowledge. I authorize Lucas County Health Center to verify information provided in this application.
Signature of Applicant

Clear
Date

MonthDayYear
Date
Should be Empty:

APPLICANT INFORMATION: