Mail Completed Application to - PDF document

1 Mail Completed Application to: Cone He
Mail Completed Application to: Cone Health Business office Attention: Customer Service 1200 N. Elm, Greensboro, NC 27401 Cone Health Financial Assistance Application Please enclose with your application:  Most recent IRS form 1040  Last 3 months pay stubs from all working household members  Copy of food stamp award  Last 3 months bank statements and brokerage statements  Letter of support  Proof of residency Account # Date(s) of Service The purpose of this fo r m is to p r ovide the F inancial Couns e ling D e partment with the information r equired to dete r mine the patient’s e l ig i bi l ity for financial assis t ance with their CH Patient b i ll(s). T o ensure a complete and thorough evaluation, please complete this form in its e ntirety. P a t ie n t De m og r a p hics P a tie n t’s Full N a m e (Last, First Middle) D a t e of B i r th S o cial Secu r ity# M a r it a l S t a t us P h ysicalAd d r ess C ity, St a te a nd Zip C o d e C o u n t y M ai l ing A d d r ess (If different from above) H o m e P h o n e # M o b ile P h o n e # C itize n ship S t a t us Li v ed i n U . S. S i n c e Guarantor De m og r a p hics Guarantor’s Full N a m e (Last, First Middle) D a t e of B i r th S o cial Secu r ity# M a r it a l S t a t us P h ysicalAd d r ess C ity, St a te a nd Zip C o d e C o u n t y M ai l ing A d d r ess (If different from above) H o m e P h o n e # M o b ile P h o n e # C itize n ship S t a t us Li v ed i n U . S. S i n c e E m pl o y m e n t /Inc

2 ome P a t i e nt ( mo t her if p
ome P a t i e nt ( mo t her if pa t i e nt is a minor) Spouse (f a t her if p a t i e nt is a minor) Employer Dates of Employment Currently Unemployed (check box if Yes) Cur rently Unemployed Currently Unemployed Gross Monthly Income amount $ Income Source (Please attach verification or explanation) If no income how d o you support yourself? Do you have an active bank account? If you have become unemployed in the last 90 days, please provide: Name of last employer, dates of employment, Insurance carrier during that employment, Are you eligible for COBRA benefits? Please list all household m e b ers below (Other than Patient/Guarantor listed above) Name Date of Birth Place of Birth Relation to Patient Dependent? Yes/No Heal t h I n s u r a n ce I n fo r m a t i o n Does your current employer offer health insurance Yes No Do you have any health insurance Yes No Name of Insurance Company Acknowledgement and Signatures I h e r e by ce r tify t h at t he in f o r m a t ion pr ovid e d in t h is P a tie n t F i n a ncial St a t e m e n t is t r u e , a ccu r a t e a n d c o m plete t o t h e b e st of m y kn ow le d g e . I h e r e by a u t h o r ize t h e H ospital to co n t a ct a ny p e r s o n, fi r m o r o r g a n iza t ion v e r ify a n y o f t he in f o r m a t ion g iven a n d I h e r e by a u t h o r ize a n y such p e r so n , fi r m o r o r g a niza t ion to r ele a se t o t h e H ospital a ny fina n cial in f o r m a tion it m ay r e q u e st. Signature Relationship to Patient Date Witness Signature Relationship to Patient Date