Application For Free Care For Medically Necessary Services Only
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1Eastern Maine Healthcare Systems
Application for Free Care
For Medically Necessary Services Only
EMMC
Acadia
CADEAN
BHMH
1. FACILITY WHERE MEMBERS OF YOUR HOUSEHOLD RECEIVES CARE:
INLAND
TAMC
SVH
2. PATIENT/APPLICANT
EMPLOYMENT INFORMATION
NOT EMPLOYED?
LAST DATE WORKED:
NAME:
EMPLOYER NAME:
SSN:
DOB:
HIRE DATE:
PLEASE EXPLAIN:
CELL/HOME PHONE:
JOB TITLE:
ADDRESS:
PHONE:
ADDRESS:
MARITAL STATUS:
MR#:
(Office Use)
3. SIGNIFICANT OTHER/CO-APPLICANT
EMPLOYMENT INFORMATION
NOT EMPLOYED?
NAME:
EMPLOYER NAME:
LAST DATE WORKED:
SSN:
DOB:
HIRE DATE:
PLEASE EXPLAIN:
CELL/HOME PHONE:
JOB TITLE:
ADDRESS:
PHONE:
ADDRESS:
MARITAL STATUS:
MR#:
(Office Use)
√ √ √ √ IF IN
√ √ √ √ IF CLAIMED
4. DEPENDANTS IN THE HOUSEHOLD
MR#
RELATIONSHIP
DATE OF BIRTH
HOUSEHOLD
ON TAXES
(Office Use)
5. GROSS HOUSEHOLD MONTHLY INCOME
6. HOUSEHOLD ASSETS
APPLICANT
CO-APPLICANT
WAGES & SALARIES
CASH
DIVIDENDS / INTEREST / RENTAL INCOME
CHECKING ACCOUNT
SHORT/LONG TERM DISABILITY
SAVINGS ACCOUNT
BUSINESS/SELF-EMPLOYMENT
LIFE INSURANCE VALUE
SOCIAL SECURITY INCOME/RETIREMENT
ANNUITIES BALANCE
SOCIAL SECURITY DISABILITY (SSDI)
STOCKS & BONDS VALUE
WORKERS COMPENSATION
PROPERTY–YEARS OWNED
MILITARY / PENSION
VEHICLES (YEAR/MAKE)
UNEMPLOYMENT BENEFITS
OTHER VEHICLES VALUE
ALIMONY / CHILD SUPPORT
BUSINESS EQUIP VALUE
OTHER INCOME:
OTHER ASSETS:
$
$
TOTALS
TOTALS
$
MONTHLY
7. MONTHLY EXPENSES/LIABILITIES
8. INSURANCE INFORMATION
PAYMENTS
BALANCE DUE
HAS ANYONE IN THE HOUSEHOLD APPLIED FOR
RENT / MORTGAGE PAYMENT
MAINECARE IN THE PAST 3 MONTHS? _______
OTHER MORTGAGE PAYMENTS
IF YES: ATTACH COPY OF DETERMINATION LETTER
PERSONAL OR STUDENT LOANS
CHARGE ACCOUNTS
DOES ANYONE IN THE HOUSEHOLD HAVE
PRESCRIPTIONS, MEDICAL BILLS
INSURANCE? _______
ELECTRICITY, WATER, PHONE, GROCERIES
IF YES: ATTACH COPY OF CARD/S
OTHER EXPENSES:
TOTALS
9. SIGNATURES
Sign Here
_____________________________________________
_____________________________________________
PATIENT/APPLICANT
DATE
CO-APPLICANT
DATE
I/We certify that all the information provided is true and complete.
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Parent category: Medical