Patient Application

Income Source

	Monthly Income	Annualized Total
1. Gross Employment Income
2. Unearned Income
3. Self-Employment Income
4. Total Income (Lines 1 + 2 + 3)
5. Allowable Deductions (See Worksheet 3)
6. Grand Total Annual Income

	Monthly Income
5. Allowable Deductions (See Worksheet 3)
6. Grand Total Annual Income

Household Size:
PENALTY CLAUSE,CONFIRMATION STATEMENT AND AUTHORIZATION FOR RELEASE OF INFORMATION
I certify that the information provided to complete this application is true and correct to the best of my knowledge. Additionally, if I misrepresent my eligibility knowing that I am not eligible, I may be charged with a crime.

I authorize the provider to use any information contained in the application to verify my eligibility for assistance under Relias Discounted Care.

I understand that if I am a legal immigrant or legally present non-citizen, I agree to refrain from executing an affidavit of support for the purpose of sponsoring an immigrant.

I understand it is my responsibility to notify the provider of an income or household change that may influence the rating on this application.
Print Patient/Applicant Name
Applicant Signature

Clear
Date

MonthDayYear
Patient was contacted by

phoneemailother
To Be Completed By Technician
Print Eligibility Technician Name
Eligibility Technician Signature

Clear
Date

MonthDayYear
Application Notes:
ApprovedDoesn't meet criteria

	Monthly Income	Annualized Income
Employment Income

	Monthly	Annualized
Gross Business Income

Business Property Expenses:

	Monthly	Annualized
Mortgage/Rent of Business Property
Utilities
____________________
____________________

Other Expenses:

	Monthly	Annualized
Advertising
Business Phone
Business Taxes (non-personal)
Fuel for Business-related Travel
Gross Wages
Insurance
Legal Fees
License/Certification Fees Paid
Merchandise/Cost of goods
Office Supplies
Repairs/Upkeep of Equipment
Tools/Equipment
____________________
____________________

	Monthly	Annualized
Total Expenses
Total Expenses Attributed to Business
Net Profit

To Be Completed By Technician
Eligibility Technician Signature

Clear
Date

MonthDayYear
Facility
Date

MonthDayYear
This worksheet only needs to be signed and included if the applicant owns their own business.

	Monthly Income	Annualized Income	Documented	Self-Declared
Social Security Income (SSI)
Social Security Disability Income (SSDI)
Disbursement from Retirement Account
Pension Payments
Payments from Trust Funds
Disbursement from Lottery Winnings

	Monthly Income	Annualized Income	Documented	Self-Declared
Bonuses (enter full amount of bonuses included on pay stubs)
Short Term Disability (enter full amount of payments from STD)
Unemployment Income (enter full amount of current UBI bank)
Tips and Commissions (only if not normal on paystub)
Infrequent Overtime

Section I: PATIENT/APPLICANT