2022 CARES Application (English)

ST. ANTHONY REGIONAL HOSPITAL & NURSING HOME

FINANCIAL APPLICATION | CARES PROGRAM
What do I need to do?
1. Complete this application & return required information to the Patient Finance Department at St. Anthony Regional Hospital, P.O. Box 628, Carroll, Iowa 51401
2. Apply for Medicaid for every individual that is applying for the financial assistance program and return the Notice of Action letter to us when you receive it (this normally takes 30-45 days to receive)
  www.dhs.iowa.gov
3. Include a copy of last year’s Complete Federal Tax Return including all Schedule’s and Forms for yourself and all adults living in your home. If you did not file income taxes provide the last 3 months’ worth of pay stubs for everyone in the household earning income. If anyone in the household is working and receiving cash payment a letter stating the amount of cash paid and the frequency paid is required from the payer.
Please direct any questions to: 712-794-5233
Applicant & Spouse Information
First Name
Middle Name
Last Name
Spouse First Name
Spouse Middle Name
Spouse Last Name
Your Government ID Number
Spouse Government ID Number
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Household Members
Please list all people living in your home. (Start with yourself) Please consider applying for all family members at this time as your application will be good for 1 year.
Household Members
Income Information
Income (List all income received by the adults living in your home. Include income from work, self-employment, social security, veteran’s benefits, unemployment insurance, child support, worker’s compensation, retirement, IPERS, pensions, civil service, cash from family or friends)

You must provide along with your completed application a copy of last year’s Complete Federal Tax Return, including any schedules and forms that provide details of income. If you did not file taxes, a copy of the last three (3) months’ worth of paystubs, social security income, disability income or any other income your household receives will be sufficient. If anyone in the household is working and receiving cash payment a letter stating the amount of cash paid and the frequency paid is required from the payer.
Total household income.
Health Insurance
Do you have health insurance?
Is your health insurance obtained through your employer?
Name of Employer (Health Insurance)
Policy Holder Name
Policy Number
Applicant Acknowledgement
PLEASE READ AND SIGN BELOW

I understand that I assume full responsibility of the accuracy of the statements on this form, and I understand that St. Anthony Regional Hospital will use these statements to determine my eligibility for the CARES program. If any information changes, it is my responsibility to report such changes. I further understand that any false representations or false claims, statements, or documents or concealments of any material fact may result in the immediate termination of any financial assistance granted to me or my family and that I will be liable to repay all amounts of financial assistance previously provided to me.

I certify that the information given on this application and any attached supporting document is accurate and complete to the best of my ability. I authorize St. Anthony Regional Hospital/Clinic to investigate in reviewing my application for financial assistance.

By signing this form I acknowledge that I have read and agree to the St. Anthony Regional Hospital Financial Assistance Policy and all of the requirements and guidelines.
I have read and agree to the St Anthony Regional Hospital Financial Assistance Policy and all requirements and guidelines.
Signature of Applicant
Date of Applicant Signature

MonthDayYear
Date
Signature of Co-Applicant
Date of Co-Applicant Signature

MonthDayYear
Date
- Financial Assistance Policy
- Amounts Generally Billed
Should be Empty:

ST. ANTHONY REGIONAL HOSPITAL & NURSING HOME

What do I need to do?

Applicant & Spouse Information

Household Members

Income Information

Health Insurance

Applicant Acknowledgement

PLEASE READ AND SIGN BELOW