Financial Assistance Program Application & Instructions
NAME OF PATIENT DATE OF BIRTH MEDICAL RECORD NUMBER
NAME OF RESPONSIBLE PARTY( Guarantor) SOCIAL SECURITY NUMBER HOME PHONE NUMBER
ADDRESS RELATIONSHIP TO PATIENT EMPLOYER
YEARS / MONTHS EMPLOYED |
OCCUPATION |
|
|
SPOUSE’ S NAME( or other parent if patient is a minor) |
SOCIAL SECURITY NUMBER |
SPOUSE’ S EMPLOYER |
YEARS / MONTHS EMPLOYED |
OCCUPATION ADDRESS( if different from above) PHONE NUMBER
GUARANTOR INFORMATION:
1. BANK / CREDIT UNIONS / TRUST REFERENCES AND ACCOUNTS:
NAME TYPE & ACCT NUMBER
2. LIFE INSURANCE POLICIES: NAME OF POLICY TYPE & POLICY NUMBER CASH VALUE
3. ASSETS( See instructions page for other asset account examples)
4. BUSINESS OW NERSHIP:
NAME & ADDRESS TYPE OF INTEREST HELD
5. MISCELLANOUS
6. ARE YOU ELIGIBLE FOR ANY GOVERNMENT ASSISTANCE? IF SO, PLEASE LIST BELOW □ YES □ NO
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. I ALSO AUTHORIZE RENOWN HEALTH TO OBTAIN INFORMATION NECESSARY FOR VERIFICATION OF MY FINANCIAL POSITION.
____________________________________________________________________________ Patient or Patient’ s Representative Signature
Date / Time
______________________________________________________________________________ Patient or Patient’ s Representative Printed Name
Date / Time
Following a determination of FAP eligibility, a FAP-eligible individual may not be charged more than the AGB for emergency or other medical necessary care. As of 9 / 01 / 2022 the AGB is 26 % of charges. For information on how the AGB is calculated please contact us at 775-982-5747.
Page 2 of 2 Form Number: 100-169 Revision Date: 1 / 2026