AIOF Application of Financial Assistance

Application of Financial Assistance
For questions, please call (907)-302-4845 Or email: Financialassistance@radiationbusiness.com
Name*

First NameLast Name
Radiation Center*
Birthdate

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone*
Marital Status*

SingleMarried/ PartneredDivorcedSeparatedWidowed

Financial Information

	Include Guarantor, Self, Spouse, & Dependents Claimed on Taxes	Date of Birth	Relation to Patient	Monthly Gross Income	Source of Income
1
2
3
4
5

Total Monthly Net Income*
If you do not have monthly wages listed above, please explain how you take care of your monthly living expenses:
If unemployed provide the date employment ended

MonthDayYear
Date
Have you applied for unemployment or COBRA?

YesNo
Are you currently insured?*

YesNo
If uninsured, have you applied or been approved for Medicad/Disability?

YesNo
If you have applied for Medicad/Disability what is the current status?

Real Estate*

	Rent or Own	Monthly Payment
Primary Residence

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

List all assets (Make/Model/Year), Properties (Not Primary Residence), Etc.

Banking Information*

Provide any other information supporting your financial position or describe any financial hardships.
The following are examples of documents needed based on your responses in the application:
- Paycheck stubs or your most recent federal income tax return
- Letter or bank statement verifying Social Security, SSI, or other government benefits received
- Bank statements for checking, savings, or investment accounts
- Tax statements showing the value of real estate and personal property (excluding primary residence)
Upload the requested documents that are referenced above*

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*

Clear
DATE*

MonthDayYear
Date
In order for Aurora to comply with state and federal guidelines, each item listed on this application must be completed and requires proof of documentation. Your application will be delayed, and your account(s) will progress through our collection cycle until all required documentation is received.
Should be Empty: