Financial Disclosure Form - Saint Simons By-The-Sea printable pdf download

Financial Disclosure Form - Saint Simons By-The-Sea

FINANCIAL DISCLOSURE FORM

______________________________________________________________________________________

Patient/Guarantor

Patient Account Number

______________________________________________________________________________________

Social Security Number

Date of Birth

______________________________________________________________________________________

Employer

Phone Number

Gross Monthly Income:

$___________

Additional Income (Child Support/Alimony/Etc.):

$___________

Total Monthly Gross Household Income:

$___________

Number of Dependents (including Self):________

Housing: Own or Rent (circle one)

Monthly Payment: $_________

Do you have any of the assets listed below? If so, please provide details.

Checking Account:

$____________

Savings Account:

$____________

Money Market Fund/Stocks:

$____________

Please list any other financial information to be considered in determining your ability for payment:

_____________________________________________________________________________________

To receive healthcare at a reduced cost to you, you must cooperate fully with our need for accurate

and detailed financial information, including the timely production of necessary documentation to

support this disclosure. Completion of this form does not guarantee that you will be eligible for a cost

reduction in your healthcare.

I authorize representatives of St. Simons By The Sea and its affiliates to verify the information on

this form and to release any of my information for payment purposes. The information given above is

true and complete and I agree to notify St. Simons By The Sea of any changes in my financial

situation. I further authorize St. Simons By The Sea and its affiliates to review and inquire into my

credit history using any means available, including a credit bureau history report.

Signed: _________________________________________ Date: _________________________

Witness: ________________________________________ Date: _________________________

Financial Disclosure Form - Saint Simons By-The-Sea