Application of Financial Assistance AIOF

Application of Financial Assistance
For questions, please call (907)-302-4845 or email financialassistance@radiationbusiness.com
Patient Name:
First and Last Name
Radiation Center:
Birthdate:

MonthDayYear
Date
Email:
example@example.com
Address:
Please include street address, city, state, and zip
Phone:
Format: (000) 000-0000.
Marital Status:

Rows	GUARANTOR, SELF, SPOUSE AND DEPENDENTS CLAIMED ON TAXES	DATE OF BIRTH	RELATION TO PATIENT	MONTHLY NET INCOME	SOURCE OF INCOME
1
2
3

Total Monthly Net Income:
If no monthly wages are listed, please explain how you take care of your living expenses:
If unemployed, provide the date employment ended:

MonthDayYear
Date
Have you applied for unemployment or COBRA?
Are you currently insured?
If uninsured, have you applied for Medicaid/Disability?
If yes, what is the current status?
What is your current housing status?
Monthly payment (rent or mortgage):

Please list any other monthly expenses (Utilities, Loans, Credit Cards, Premiums, etc.):

Provide any other information supporting your financial position, or describe any financial hardships:
Please submit copies of the following documents in support of the information provided above:
- Paycheck stubs
- Federal income tax return
- Proof of Social Security or government benefits (letter or bank statement)
- Bank statements for checking and/or savings
Cancelof
I certify that the information provided in this application is, to the best of my knowledge, complete, accurate, and true. I understand that fraudulent or misleading information will make me ineligible for financial assistance. I authorize the release of any information needed by Aurora to verify the information provided. Should I be referred to a federal or state-funded medical assistance program, I authorize Aurora to release and obtain all information needed to determine eligibility for that funding.
Applicant Signature:
Date:

MonthDayYear
Date
In order for AIOF to comply with state and federal guidelines, each of the items listed on this application must be completed and requires supporting documentation. Your application will be delayed, and your account(s) will continue through our collection cycle until all required documentation has been received.
Should be Empty: