Financial Assistance Application

Financial Assistance Application

No one will be denied access to medically necessary services based on inability to pay.
For Services Provided By:

Frances Mahon Deaconess Hospital

FMDH Glasgow Clinic Primary Care

FMDH Glasgow Clinic Specialty Care

Please call us at (406) 228-3633 to speak with our Financial Counselor.
Payment Options:

At Frances Mahon Deaconess Hospital, we understand that medical bills may occur when you least expect them. To help with these bills, please see options below.
Financial Assistance:
Financial assistance is a discount on your bill, based on your income and assets minus debts. To apply, fill out this form. To check if you may qualify, please refer to the chart below. Find your family size in the left hand column and look across to see where your total income falls. The actual amount of your discount may depend on the value of your assets minus your debts.

Elective services are excluded from this program. Refer to the interest free payment plans for these services.
Interest Free Payment Plans:

We offer a monthly payment plan for up to 12 months without an application. To extend payments beyond 12 months, please fill out this application.
Lump Sum Payment:

We have smaller monthly payment plans that include a lump sum payment payable when an income tax refund or a farm payment is received.
Application Checklist:
Submit Proof of Income:

Paystubs or proof of other monthly income sources for the last 90 days. This could include social security income, pension benefits, etc. (See Monthly Income Section)A complete copy of your most recent tax return(s) including all schedules.If you are claimed on another tax return, please provide that return as well.Any other information that may be necessary to qualify such as financial statements used for operating notes.
Filled in all fields

Yes
Signed and dated application

Yes
Returned within 10 days

Yes

Financial Assistance & Extended Payment Plan Application:

Please fill in all lines on this form
Head of Household:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Social Security Number:*
Spouse/Partner:

First NameLast Name
Spouse/Partner Date of Birth:

MonthDayYear
Date
Spouse/Partner Social Security Number:
Street Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from Street Address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*

Area CodePhone Number
Marital Status:*

MarriedSingleDivorcedWidowed
Employer:*
How many years/months?*
Spouse Employer:
How many years/months?
Disabled?*

Yes (please add date below)No
Applied for Disability:

MonthDayYear
Date
Dependents:

Please list First and Last name
How many dependents do you have?

Dependent 1
Information:

First Name

Last Name

Relationship

Age

Dependent 2
Information:

First Name

Last Name

Relationship

Age

Dependent 3
Information:

First Name

Last Name

Relationship

Age

Dependent 4
Information:

First Name

Last Name

Relationship

Age

Dependent 5
Information:

First Name

Last Name

Relationship

Age

Dependent 6
Information:

First Name

Last Name

Relationship

Age

Assets & Debts:

Please fill out all lines on this form
Home (if owned) Estimated Value:
Home (if owned) Amount Owing:
Vehicles:
Vehicle Year:
Model:
Estimated Value:
Amount Owing:
Vehicle Year:
Model:
Estimated Value:
Amount Owing:
Vehicle Year:
Model:
Estimated Value:
Amount Owing:
RV/Boat/Motorcycle:
RV/Boat/Motorcycle Year:
Model:
Estimated Value:
Amount Owing:
RV/Boat/Motorcycle Year:
Model:
Estimated Value:
Amount Owing:
Other Loans:

Student Loans, Operating Loans, etc.
Other Loan Type:
Amount Owed:
Other Loan Type:
Amount Owed:
Checking & Savings Accounts:
Checking Account Balance:
Bank or Institution:
Savings Account Balance:
Bank or Institution:
Investments:

Please list any Stocks/Mutual Funds, Mineral Rights, IRAs, CDs, Rental Properties, etc.
Investment Type:
Amount:
Investment Type:
Amount:
Investment Type:
Amount:
Investment Type:
Amount:
Settlements & Inheritance:
Settlement Pending:*

YesNo
Amount:
Inheritance Pending:*

YesNo
Amount:

Monthly Expenses:

Please fill out all lines on this form
Rent or House Payment:
Rent or House Payment:
ex: $1,000 every month
Car Payments (total):
Car Payments (total):
ex: $1,000 every other month
RV/Boat/Motorcycle Payments (total):
RV/Boat/Motorcycle Payments (total):
ex: $1,000 twice per year
Student Loan Payment:
Student Loan Payment:
ex: $1,000 per month
Other Loan Payment:
Other Loan Payment:
ex: $1,000 once per year
Food:
Food:
ex: $1,000 every month
Electricity/Gas:
Electricity/Gas:
ex: $1,000 every other month
Phone/Cell Phone/Internet:
Phone/Cell Phone/Internet:
ex: $1,000 per month
Pharmacy/Drugs:
Pharmacy/Drugs:
ex: $1,000 every month
Water:
Water:
ex: $1,000 every month
Cable/Satellite TV:
Cable/Satellite TV:
ex: $1,000 every month
Auto Insurance:
Auto Insurance:
ex: $1,000 every year
Health/Life Insurance:
Health/Life Insurance:
ex: $1,000 every year
Property Insurance:
Property Insurance:
ex: $1,000 twice per year
Car Expense/Gas:
Car Expense/Gas:
ex: $1,000 every month
Child Care:
Child Care:
ex: $1,000 twice per month
Child Support/Alimony:
Child Support/Alimony:
ex: $1,000 twice per month
Other Expense:
Please list the expense
Other Expense:
ex: $1,000 for this and $500 for that.
Other Expense total:
Collections Owing:
Collections Owing:
ex: $1,00o per month
Collections Payment:
Collections Payment:
ex: $1,000 every other month
Credit Cards Owing:
Credit Cards Owing:
ex: $1,000 every other month
Credit Cards Payment:
Credit Cards Payment:
ex: $1,000 per month
Doctor Name:
Doctor Amount Owing:
Doctor amount Owing:
ex: $1,000
Doctor Payment Amount:
Doctor payment amount:
ex: $1,000
Dentist Name:
Dentist Owing Amount:
Dentist owing amount:
ex: $1,000
Dentist Payment Amount:
Dentist payment amount:
ex: $1,000
Hospital Name:
Hospital Owing Amount:
Hospital owing amount:
ex: $1,000
Hospital Payment Amount:
Hospital payment amount:
ex: $1,000
TOTAL of all fields:*
TOTAL OF ALL FIELDS:
ex: $20,000

Monthly Income:

Proof of Income required.
Employment (Gross Wages):*
Part-Time Jobs (Gross Wages):
Social Security:
Social Security Disability:
Disability Pension:
Veteran Pension:
Retirement (all sources):
Unemployment Compensation:
Workers Compensation:
Union Benefits:
Inheritance:
Public Assistance (TANF):
Snap (Food Stamps):
Alimony/Child Support:
Rents/Royalties:
Savings Interest Income:
Investment Income:
Other Income:
Please tell us the source
Other Income total:
TOTAL of all sources of income listed:*
If you are claiming no income, how are you paying for living expense?
Please provide any additional information that you would like to be considered as part of your application.

Health Insurance:
Do you expect to have Health Insurance?

YesNo
If yes, start date:

MonthDayYear
Date
If no, please explain:
Would you like more information about the Healthy Montana Kids (HMK) Program?

YesNo
For more information on Health Insurance, go to HealthCare.gov or call +1 (800) 318-2596.

Certification:
I understand additional information may be requested to qualify. False information will result in a denied application.*

Yes
Signature, Head of Household:*

Clear
Today's Date:*

MonthDayYear
Signature, Spouse:

Clear
Today's Date:

MonthDayYear
Proof of Income (for last 90 days):*

Browse Files

Cancelof
Other Proof of Income:

Browse Files

Cancelof
Most recent tax return:

Browse Files

Cancelof
Tax return you're claimed on:

Browse Files

Cancelof
Financial statements for operating notes:

Browse Files

Cancelof
Additional Information to be considered:

Browse Files

Cancelof
Should be Empty:

Financial Assistance Application

Payment Options:

Financial Assistance:

Interest Free Payment Plans:

Lump Sum Payment:

Application Checklist:

Financial Assistance & Extended Payment Plan Application:

Dependents:

Assets & Debts:

Vehicles:

RV/Boat/Motorcycle:

Other Loans:

Checking & Savings Accounts:

Investments:

Settlements & Inheritance:

Monthly Expenses:

Monthly Income:

Health Insurance:

Certification: