Financial Assistance Application

Financial Assistance Application
PROOF OF INCOME is required as explained below.
Primary Applicant (Parent if patient is a minor)
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
Phone*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Enrolled in: Medicaid?*

YesNo
Medicare?*

YesNo
Spouse or Significant Other Information
Name

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
Date
Phone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Enrolled in: Medicaid?

YesNo
Medicare?

YesNo
Dependent's Information (Please note: only dependents claimed on your Federal tax return may be included here—attach a piece of paper for additional dependents if needed)
Dependent 1 Name

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
Date
Medicaid?

YesNo
Medicare?

YesNo
Dependent 2 Name

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
Date
Medicaid?

YesNo
Medicare?

YesNo
Dependent 3 Name

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
Date
Medicaid?

YesNo
Medicare?

YesNo
Dependent 4 Name

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
Medicaid?

YesNo
Medicare?

YesNo
THIS APPLICATION APPLIES TO ALL OF OUR PRACTICES (some services may not apply)
Lamoille Health Family Medicine, Morrisville & Cambridge| Lamoille Health Family Dentistry
Lamoille Health Behavioral Health & Wellness | Lamoille Health Pediatrics
Estimated Monthly Household Income (Proof of income must be provided, which may include: a copy of a recent pay stub, Social Security determination letter, or tax return if self-employed)
Gross Wages (Before Tax)
Worker's Compensation
Alimony Received
Pensions
Unemployment
Social Security
State/Federal Assistance
Other Income
(Please Specify)
Use of Personal Financial Information Disclosure, Authorization and Release for Application for Assistance
I hereby authorize Lamoille Health Partners to utilize the financial information I am providing, to process my application for financial assistance as a patient at Lamoille Health Partners. I certify all of the information provided on or with this application is true and accurate.
PROOF OF INCOME ENCLOSED?*

YesNo, will bring in to office
File Upload

Cancelof
You may also deliver Proof of Income to the office directly, if unable to upload electronically.

(Proof of income must be provided within 7 business days to be eligible for any discount you may receive today)
Electronic Signature Acknowledgment: By typing my name below, I acknowledge that I have reviewed the information provided and certify that it is true and accurate to the best of my knowledge. I understand that typing my name constitutes my electronic signature.*
Full Name
Date*

MonthDayYear
Date
Signature of Primary Applicant

Clear
Should be Empty:

Financial Assistance Application

Primary Applicant (Parent if patient is a minor)

Spouse or Significant Other Information

Dependent's Information (Please note: only dependents claimed on your Federal tax return may be included here—attach a piece of paper for additional dependents if needed)

Estimated Monthly Household Income (Proof of income must be provided, which may include: a copy of a recent pay stub, Social Security determination letter, or tax return if self-employed)