Online Application

Welcome to your Pana Community Hospital online financial assistance application!
In order to process your application, we need supporting documents to verify your financial situation. Required documents include any of the following that apply to your household:
After reviewing your submitted application, we may reach out to assist you with additional programs and insurance options available to you.

Please get an electronic copy or pictures of your documents ready before starting your application. If you submit an incomplete application, we will reach out to you via mail for any additional information or documentation needed to process your application.
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
What is the APPLICANT'S gross monthly income from all sources? If none, enter 0.

Online Application

The following questions regarding race, ethnicity, sex, and preferred language are OPTIONAL. Responses or non-responses will not have any impact on the outcome of the application.
Race
Ethnicity
Sex
Preferred Language

Online Application
Including yourself, what is the total number of people living in your household?
Additional Household Member 1 - Name

First NameLast Name
Additional Household Member 1 - Date of Birth

MonthDayYear
Additional Household Member 1 - Relationship to Applicant
What is Additional Family Member 1's gross total monthly income from all sources? If none, enter 0.
Additional Household Member 2 - Name

First NameLast Name
Additional Household Member 2 - Date of Birth

MonthDayYear
Additional Household Member 2 - Relationship to Applicant
What is Additional Family Member 2's gross total monthly income from all sources? If none, enter 0.
Additional Household Member 3 - Name

First NameLast Name
Additional Household Member 3 - Date of Birth

MonthDayYear
Additional Household Member 3 - Relationship to Applicant
What is Additional Family Member 3's gross total monthly income from all sources? If none, enter 0.
Additional Household Member 4 - Name

First NameLast Name
Additional Household Member 4 - Date of Birth

MonthDayYear
Additional Household Member 4 - Relationship to Applicant
What is Additional Family Member 4's gross total monthly income from all sources? If none, enter 0.
Additional Household Member 5 - Name

First NameLast Name
Additional Household Member 5 - Date of Birth

MonthDayYear
Additional Household Member 5- Relationship to Applicant
What is Additional Family Member 5's gross total monthly income from all sources? If none, enter 0.
Additional Household Member 6 - Name

First NameLast Name
Additional Household Member 6 - Date of Birth

MonthDayYear
Additional Household Member 6 - Relationship to Applicant
What is Additional Family Member 6's gross total monthly income from all sources? If none, enter 0.
Additional Household Member 7 - Name

First NameLast Name
Additional Household Member 7 - Date of Birth

MonthDayYear
Additional Household Member 7 - Relationship to Applicant
What is Additional Family Member 7's gross total monthly income from all sources? If none, enter 0.
If your household's total income is zero, please provide an explanation for how you are being supported.If your

Online Application

Banking and Current Asset Information. Please provide the current balance/value in each of the following categories. If none, enter 0.
Applicant's Savings Account(s) - Total Balance
Applicant's Checking Account(s) - Total Balance
Applicant's Health Savings Account(s) - Total Balance
Applicant's Non-Primary Residence Real Estate - Total Value
Spouse/Other Savings Account(s) - Total Balance
Spouse/Other Checking Account(s) - Total Balance
Spouse/Other Health Savings Account(s) - Total Balance
Spouse/Other Non-Primary Residence Real Estate - Total Value

Online Application
Did the patient have health insurance at the time of hospital service?
Are these services a result of a worker's compensation claim or motor vehicle accident?

Online Application

This section is for attaching the documents we need to fully process your application and verify the information you provided. Please include copies of all of the following that apply to your household.
Pay Stubs - Please upload paystubs for all income earners for the past 2 months, if applicable.

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Other Income Statements - Please upload any other statements you receive from income sources (Social Security, alimony/child support, unemployment, retirement/pension, etc.) for the past 2 months, if applicable.

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Tax Return - Please upload your tax return from last year, if applicable.

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Bank Statements - Please upload your statements from your checking and savings accounts for the past 2 months.

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Online Application
Signature of Applicant
I certify that the above information is true and accurate to the best of my knowledge. I will apply and take any reasonable action needed to get assistance (Medicaid, Medicare, Insurance, etc.) to pay my hospital charges. Financial assistance is a source of last resort. Any other liability or possible payer will be exhausted prior to awarding assistance. I understand that this application is made so that the hospital can see if I am eligible for financial assistance based upon defined criteria.
Signature

Online Application
Are you ready to submit your application?
On a scale from 1-5, with 1 being HARD and 5 being EASY, how was our experience applying for Financial Assistance online?
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