Application For Sbl Financial Assistance (Page 2 of 2) in pdf

Application for SBL Financial Assistance

PATIENT’S FAMILY INCOME &

CERTIFICATION

If you need any help with this form, please call 800-381-0040.

EMPLOYMENT INFORMATION

I certify that the information in this application is

PATIENT INFORMATION

Patient’s Employer Name ___________________________

true and correct to the best of my knowledge. I

will apply for any state, federal or local assistance

Patient’s Employer Address__________________________

Name ____________________________________________

for which I may be eligible to help pay for this

Patient’s Employer Phone ___________________________

hospital bill. I understand that the information

Date of Birth ______________________________________

Guarantor/Spouse/Partner Employer Name

provided may be verified by the hospital,

______________________________________________

Address __________________________________________

and I authorize the hospital to contact third

Guarantor/Spouse/Partner Employer Address

parties to verify the accuracy of the information

______________________________________________

_________________________________________________

provided in this application. I understand that

Guarantor/Spouse/Partner Employer Phone

if I knowingly provide untrue information in

Social Security # ___________________________________

______________________________________________

(not required if you are uninsured)

this application, I will be ineligible for financial

assistance, any financial assistance granted to me

INSURANCE INFORMATION

Telephone or cell phone number _______________________

may be reversed, and I will be responsible for the

o Patient o Guarantor o Spouse o Partner

payment of the hospital bill.

GUARANTOR INFORMATION

Health Insurance Name ________________________________

Spouse, Partner and Parent or Guardian for a minor, must

o Medicare

complete the following.

o Medicare Supplement Name _________________________

_________________________________________

Applicant Signature

o Medicaid

Guarantor Name __________________________________

_________________________________________

ANNUAL INCOME:

Signature Date

Guarantor Address ________________________________

.00

Patient wages

_________________________________________________

Guarantor/Spouse/Partner’s

.00

wages

Please see back panel for additional

Guarantor phone number ___________________________

information.

Farm or Self-employment

.00

Income

FAMILY/HOUSEHOLD INFORMATION

Temporary Assistance for

.00

needed families

Dependent’s Names:

.00

Social Security/Disability