Appointment Request

Name*

FirstLast
Date of Birth*

MonthDayYear
Date
Address*

Address Line 1

Address Line 2

CityState

Zip Code
Phone*
Email - Applicant*
SSN (xxx-xx-xxxx)*
Do you have a co-applicant?*

YESNO
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Address Line 1

Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
OPTIONAL DETAILS
This may aid you in qualifying for a federal or state assistance program such as Medicaid or Disability.
Are you pregnant?

YESNO
Are you disabled?

YESNO
Do you have dependents?

YESNO
Dependent 1*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Dependent 2

First NameLast Name
Date of Birth

MonthDayYear
Date
Dependent 3

First NameLast Name
Date of Birth

MonthDayYear
Date
Dependent 4

First NameLast Name
Date of Birth

MonthDayYear
Date

INCOME & OTHER ASSETS
Monthly Net Income (Please Fill in Dollar Amount Where Acceptable)
Income*
Spouse's Income
Alimony/Child Support
Rental Income
Other
Assets (Please Fill in Dollar Amount Where Acceptable)
Life Insurance Cash Value
Stocks/Bonds/Mutual Funds
Retirement Plans
Saving Accounts
Real Estate (Net Cash Value)
Other

INCOME TAXES
Which applies to you?*

I have not filed for income taxes in the past two years due to low-income status.I am up-to-date on my income tax filing.
PARTIAL COMMUNITY CARE AGREEMENT
Payment plans arranged with partial Community Care Application awardees are considered reasonable by the Patient Accounts Coordinator.
I promise to pay Jamestown Regional Medical Center (JRMC) the remainder of my bill, if I receive Partial Community care to cover a portion of my current bill. I have been informed of JRMC's payment plan and have reviewed it above. If I default on this plan, I know that the hospital can take action to see that they are paid for the services that were offered including, but not limited to, sending my account to a collection agency.

The information stated in this application is correct to the best of my knowledge. You are authorized to check my credit and employment history and to answer questions about your credit experience with me.

You are further authorized to disclose any information contained herein and other information obtained by you with regard to my credit and employment history to third parties, solely for the purpose of obtaining financing for payment of any indebtedness that I might owe you.

By signing this agreement I am promising to cooperate with the hospital staff and provide adequate information, in a timely manner, to get my bill resolved. I understand that my signing this form gives JRMC the right to verify this information and deny me of Community Care if I am fraudulent.
Checkboxes*

I acknowledge that I've read and reviewed the Community Care guidelines and financial assistance policy.
Date*

MonthDayYear
Date

GATHER, COPY, & SCAN DOCUMENTS
By presenting proof, your eligibility can be better assessed. These materials include:

-income taxes for the past two years (if you don't file income taxes, please provide your two most recent W-2 forms or the last six pay stubs from your employer included in this packet to verify that they were not filed)

-additional documentation of income needed for verification if you are: receiving income from another source such as SS. retirement, alimony, child support, VA or welfare, or making payments to another source such as alimony or child support

-three recent bank statements

-six recent pay stubs

-Notification of Benefit Decision from the ND Department of Health and Human Services
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
Comments
Should be Empty:

OPTIONAL DETAILS

INCOME & OTHER ASSETS

INCOME TAXES

PARTIAL COMMUNITY CARE AGREEMENT

GATHER, COPY, & SCAN DOCUMENTS