Financial Assistance Program Application

Patient Information

Complete information that is applicable
Patient's Name*

First NameMiddle Name (optional)Last Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Phone Number*
Please enter a valid phone number.
Parent/Guardian or Lawful Representative Name (if patient is a minor child or an incapacitated adult)

First NameLast Name
Email
example@example.com
Family Information

Please list below all family members in your household. Your household includes yourself, your spouse or domestic partner, and any children or other dependents. For example, this would include everyone listed on the same tax return.

Gross income means your income before taxes are deducted.

Gross income can consist of work earnings (wages, salaries, tips, earnings from selfemployment), unearned income (social security, disability, and unemployment benefits), contributions (funds from family or friends), and other sources of income (temporary assistance and supplemental security income).
Family Members in your household (including yourself)*
File Upload - Please provide documentation for each family member you listed above to prove gross income. Examples of documentation might include a pay stub, a letter from your employer if applicable, or Form 1040.

Valid file types: pdf, doc, docx, xls, xlsx, csv, txt, zip, jpg, jpeg, png
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Health Insurance Status
Do you have any form of health insurance, including Medicaid, Medicare, or private insurancethrough your employer or purchased on your own?

YesNo
Please provide an estimate of the medical bills you paid in the past 12 months
The hospital may request you submit documentation as proof of paid medical expenses.
Would you like assistance in applying for any of these programs?

YesNo
Patient/Responsible Party

If not the patient, list the name of the person signing the form and their authority to sign on behalf of the patient (e.g., spouse, parent, legal representative).
Responsible Party Name

First NameLast Name
I understand that the information I submit may be subject to verification from external sources. Icertify that the information is true and complete to the best of my knowledge.
Date*

MonthDayYear
Date
Signature of Patient or Responsible Party. By typing your name below you are legally binding an e-signature.*
By typing your name above, you are legally binding an e-signature.
Relationship to Patient (if responsible party)
Household size (including yourself)*
Max number is 10
Name*

First NameLast Name
Applying for Financial Assistance?*

YesNo
Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Select the type(s) of income you receive.*

Wages and Salary – Last four (4) consecutive weeks of paystubs (two (2) if paid bi-weekly)Self – Employment – three (3) month business ledger, or a tax returnUnemployment BenefitsSocial Security (Retirement / Disability)Worker’s CompensationChild Support / AlimonyMilitary PayIncome from Rent or Room/BoardInterest/Dividends/RoyaltiesPrivate Pensions/AnnuitiesVeteran’s BenefitsNo IncomeOther
Please explain how you are supported with no income.*
Gross Income Amount (Before Taxes)*
Received how often? (Weekly, Monthly, etc.)*
Please attach proof of income files.*

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Name*

First NameLast Name
Applying for Financial Assistance?*

YesNo
Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Select the type(s) of income you receive.*

Wages and Salary – Last four (4) consecutive weeks of paystubs (two (2) if paid bi-weekly)Self – Employment – three (3) month business ledger, or a tax returnUnemployment BenefitsSocial Security (Retirement / Disability)Worker’s CompensationChild Support / AlimonyMilitary PayIncome from Rent or Room/BoardInterest/Dividends/RoyaltiesPrivate Pensions/AnnuitiesVeteran’s BenefitsNo IncomeOther
Please explain how you are supported with no income.*
Gross Income Amount (Before Taxes)*
Received how often? (Weekly, Monthly, etc.)*
Please attach proof of income files.*

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Name*

First NameLast Name
Applying for Financial Assistance?*

YesNo
Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Select the type(s) of income you receive.*

Wages and Salary – Last four (4) consecutive weeks of paystubs (two (2) if paid bi-weekly)Self – Employment – three (3) month business ledger, or a tax returnUnemployment BenefitsSocial Security (Retirement / Disability)Worker’s CompensationChild Support / AlimonyMilitary PayIncome from Rent or Room/BoardInterest/Dividends/RoyaltiesPrivate Pensions/AnnuitiesVeteran’s BenefitsNo IncomeOther
Please explain how you are supported with no income.*
Gross Income Amount (Before Taxes)*
Received how often? (Weekly, Monthly, etc.)*
Please attach proof of income files.*

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Name*

First NameLast Name
Applying for Financial Assistance?*

YesNo
Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Select the type(s) of income you receive.*

Wages and Salary – Last four (4) consecutive weeks of paystubs (two (2) if paid bi-weekly)Self – Employment – three (3) month business ledger, or a tax returnUnemployment BenefitsSocial Security (Retirement / Disability)Worker’s CompensationChild Support / AlimonyMilitary PayIncome from Rent or Room/BoardInterest/Dividends/RoyaltiesPrivate Pensions/AnnuitiesVeteran’s BenefitsNo IncomeOther
Please explain how you are supported with no income.*
Gross Income Amount (Before Taxes)*
Received how often? (Weekly, Monthly, etc.)*
Please attach proof of income files.*

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Name*

First NameLast Name
Applying for Financial Assistance?*

YesNo
Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Select the type(s) of income you receive.*

Wages and Salary – Last four (4) consecutive weeks of paystubs (two (2) if paid bi-weekly)Self – Employment – three (3) month business ledger, or a tax returnUnemployment BenefitsSocial Security (Retirement / Disability)Worker’s CompensationChild Support / AlimonyMilitary PayIncome from Rent or Room/BoardInterest/Dividends/RoyaltiesPrivate Pensions/AnnuitiesVeteran’s BenefitsNo IncomeOther
Please explain how you are supported with no income.*
Gross Income Amount (Before Taxes)*
Received how often? (Weekly, Monthly, etc.)*
Please attach proof of income files.*

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Name*

First NameLast Name
Applying for Financial Assistance?*

YesNo
Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Select the type(s) of income you receive.*

Wages and Salary – Last four (4) consecutive weeks of paystubs (two (2) if paid bi-weekly)Self – Employment – three (3) month business ledger, or a tax returnUnemployment BenefitsSocial Security (Retirement / Disability)Worker’s CompensationChild Support / AlimonyMilitary PayIncome from Rent or Room/BoardInterest/Dividends/RoyaltiesPrivate Pensions/AnnuitiesVeteran’s BenefitsNo IncomeOther
Please explain how you are supported with no income.*
Gross Income Amount (Before Taxes)*
Received how often? (Weekly, Monthly, etc.)*
Please attach proof of income files.*

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Name*

First NameLast Name
Applying for Financial Assistance?*

YesNo
Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Select the type(s) of income you receive.*

Wages and Salary – Last four (4) consecutive weeks of paystubs (two (2) if paid bi-weekly)Self – Employment – three (3) month business ledger, or a tax returnUnemployment BenefitsSocial Security (Retirement / Disability)Worker’s CompensationChild Support / AlimonyMilitary PayIncome from Rent or Room/BoardInterest/Dividends/RoyaltiesPrivate Pensions/AnnuitiesVeteran’s BenefitsNo IncomeOther
Please explain how you are supported with no income.*
Gross Income Amount (Before Taxes)*
Received how often? (Weekly, Monthly, etc.)*
Please attach proof of income files.*

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Name*

First NameLast Name
Applying for Financial Assistance?*

YesNo
Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Select the type(s) of income you receive.*

Wages and Salary – Last four (4) consecutive weeks of paystubs (two (2) if paid bi-weekly)Self – Employment – three (3) month business ledger, or a tax returnUnemployment BenefitsSocial Security (Retirement / Disability)Worker’s CompensationChild Support / AlimonyMilitary PayIncome from Rent or Room/BoardInterest/Dividends/RoyaltiesPrivate Pensions/AnnuitiesVeteran’s BenefitsNo IncomeOther
Please explain how you are supported with no income.*
Gross Income Amount (Before Taxes)*
Received how often? (Weekly, Monthly, etc.)*
Please attach proof of income files.*

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Name*

First NameLast Name
Applying for Financial Assistance?*

YesNo
Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Select the type(s) of income you receive.*

Wages and Salary – Last four (4) consecutive weeks of paystubs (two (2) if paid bi-weekly)Self – Employment – three (3) month business ledger, or a tax returnUnemployment BenefitsSocial Security (Retirement / Disability)Worker’s CompensationChild Support / AlimonyMilitary PayIncome from Rent or Room/BoardInterest/Dividends/RoyaltiesPrivate Pensions/AnnuitiesVeteran’s BenefitsNo IncomeOther
Please explain how you are supported with no income.*
Gross Income Amount (Before Taxes)*
Received how often? (Weekly, Monthly, etc.)*
Please attach proof of income files.*

Cancelof
Name*

First NameLast Name
Applying for Financial Assistance?*

YesNo
Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Select the type(s) of income you receive.*

Wages and Salary – Last four (4) consecutive weeks of paystubs (two (2) if paid bi-weekly)Self – Employment – three (3) month business ledger, or a tax returnUnemployment BenefitsSocial Security (Retirement / Disability)Worker’s CompensationChild Support / AlimonyMilitary PayIncome from Rent or Room/BoardInterest/Dividends/RoyaltiesPrivate Pensions/AnnuitiesVeteran’s BenefitsNo IncomeOther
Please explain how you are supported with no income.*
Gross Income Amount (Before Taxes)*
Received how often? (Weekly, Monthly, etc.)*
Please attach proof of income files.*

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Select if, I/We have or have not applied for Medicaid, Child Health Plus, or other health insurance to cover these services.

I/We haveI/We have not
If not, please explain reason:
By clicking Yes you agree to abide by the Terms of Service outlined above: "I certify the above information is true and accurate to the best of my knowledge. I will cooperate with any assistance which may be available for coverage regarding payment of my hospital charges. If any information I have given proves to be false, I understand Rochester Regional health may re-evaluate my financial status and take whatever action becomes appropriate."*

Yes
Should be Empty:

Patient Information

Family Information

Health Insurance Status

Patient/Responsible Party