Please list everyone who lives with you, even if they are not applying for assistance. 

Please indicate for each household member below if he/she is applying for Financial Assistance.

Proof of household income is required. Please attach proof of income with the completed application.

Proof of household income is required. Please attach proof of income with the completed application.

Proof of household income is required. Please attach proof of income with the completed application.

Proof of household income is required. Please attach proof of income with the completed application.

Proof of household income is required. Please attach proof of income with the completed application.

Proof of household income is required. Please attach proof of income with the completed application.

Proof of household income is required. Please attach proof of income with the completed application.

Proof of household income is required. Please attach proof of income with the completed application.

Proof of household income is required. Please attach proof of income with the completed application.

Proof of household income is required. Please attach proof of income with the completed application.

Consent

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.