If you wish to be considered for charity care, please print and complete this charity application and send it with supporting documentation as outlined in our
charity policy to:
SwedishAmerican Hospital
Patient Accounting
1401 East State Street
Rockford, Il 61104-9863
FINANCIAL DISCLOSURE
Account Number(s):
Please PRINT.
GUARANTOR INFORMATION:
Name:
Social Security #:
Address:
Employer:
Years there:
SPOUSE INFORMATION:
Name:
Social Security #:
Employer:
Years there:
DEPENDENT INFORMATION: List all family living with you not listed above.
NAME
BIRTHDATE
RELATIONSHIP
1.
2.
3.
4.
INCOME:
| Guarantor Salary: |
|
$ ______________________ gross per month
|
| Spouse Salary: |
|
$ ______________________ gross per month
|
| Other Income: |
|
$ ______________________ per month
|
|
|
Describe: __________________________ i.e. Disability, SSI, Pension
|
| Total Income: |
|
$ ______________________ per month
|
If you are claiming a zero income or have experienced a decrease in wages at the time of this application, please explain how you are managing your financial responsibilities, i.e., rent/mortgage, utilities, car payments.
ADDITIONAL ASSETS:
IRA: $
CD's: $
Stocks: $
Home: RENT or OWN (circle one)
Monthly Payment: $
If you own: Value $
Amount Owed: $
If you do not rent or own, please explain:
AUTO:
| 1. |
Year: ______________________ |
|
Make: ______________________
|
| |
Value: $ ______________________ |
|
Amount Owed: $ ______________________
|
| 2. |
Year: ______________________ |
|
Make: ______________________
|
| |
Value: $ ______________________ |
|
Amount Owed: $ ______________________
|
I/we understand that this application is made for SwedishAmerican Health System to judge my eligibility for financial assistance. I agree to apply for any and all assistance (Medicare, Medicaid, Insurance, etc.) and assign or pay SwedishAmerican Health System all amounts recovered.
Guarantor:
Date:
Spouse:
Date:
SHBO-2002 01/06/03
