Financial Assistance Program Application
IMPORTANT: Please read and complete the form before signing. Accurate information is needed for proper processing.
Pt. Account No: |
Date of Birth: |
Date of Application: |
NAME OF PATIENT |
DATE OF ADMISSION |
|
NAME OF RESPONSIBLE PARTY( Guarantor) SOCIAL SECURITY NUMBER HOME PHONE NUMBER
ADDRESS |
RELATIONSHIP TO PATIENT |
HOW MANY PEOPLE RESIDE IN |
|
|
HOUSEHOLD |
EMPLOYER EMPLOYER ADDRESS EMPLOYER PHONE
YEARS / MONTHS EMPLOYED
OCCUPATION
SPOUSE’ S NAME SOCIAL SECURITY NUMBER OCCUPATION YEARS / MONTHS EMPLOYED
SPOUSE’ S EMPLOYER EMPLOYER’ S ADDRESS EMPLOYER’ S PHONE NUMBER
GUARANTOR INFORMATION:
1. REAL PROPERTY: ADDRESS:
2. CASH ON HAND:
3. BANK / CREDIT UNIONS / TRUST REFERENCES AND ACCOUNTS: NAME ADDRESS TYPE & ACCT NUMBER BALANCE
4. INSURANCE POLICIES: |
|
|
NAME |
TYPE & POLICY NUMBER |
VALUE |
5. STOCKS / BONDS: DESCRIPTION
VALUE
6. BUSINESS OW NERSHIP: |
|
|
NAME & ADDRESS |
TYPE OF INTEREST HELD |
VALUE |
7. VEHICLES: DESCRIPTION
VALUE
8. DEEDS OF TRUST, NOTES:
9. MISCELLANEOUS:
10. ARE YOU ELIGIBLE FOR COUNTY OR STATE WELFARE? IF SO, DESCRIBE BASIS OF ELIGIBILITY □ 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.
SIGNATURE OF RESPONSIBLE PARTY
Date
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.