Financial Assistance Application Page 3
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4FINANCIAL ASSISTANCE APPLICATION
PRIMARY APPLICANT (Parent if patient is a minor)
Last Name_______________________________ First______________________ Middle_______
Date of Birth ______________ SSN_______________ Daytime Phone/Cell ________________
Mailing Address___________________________________________________________________
Marital Status: □ Single □ Married □ Separated □ Divorced □ Widowed
Employment Status: □
□
□
□
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Student
Retired
Disabled
Unemployed
Self-Employed
Employed
If employed, list employer(s) ____________________________________
How long employed? ______
SPOUSE or CO-APPLICANT (Must be member of household)
Last Name_______________________________ First______________________ Middle_______
Date of Birth ______________ SSN_______________ Daytime Phone/Cell ________________
Employment Status: □
□
□
□
□
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Student
Retired
Disabled
Unemployed
Self-Employed
Employed
If employed, list employer(s) ____________________________________
How long employed? _____
DEPENDENTS (Must be claimed on Federal Tax Returns)
Last name______________________ First____________ Middle___ DOB ________ SSN_______________
Last name______________________ First____________ Middle___ DOB ________ SSN _______________
Last name______________________ First____________ Middle___ DOB ________ SSN_______________
OTHER INFORMATION
Are you covered under any health insurance policy? □ No □ Yes
Is Co-Applicant: □ No □ Yes
If yes, list insurance(s): Primary: __________________ Secondary: ________________
Do you and/or your dependents have an application pending for insurance on the Health Exchange,
Medicaid, or Dr. Dynasaur? □ No □ Yes: Date applied ____________
Note: If you meet certain criteria, we may require that you apply for State Aid programs in order to process your application for financial assistance
Are you seeking financial assistance resulting from an accident or injury related to any of the
□ Work Related □ Motor Vehicle □ Other Liability □ None of these
following:
□ Yes
Did you file and/or are you required to file a Federal Tax return?
(provide copy of most recent return)
□ No:
___________
Why?
Do you reside in Vermont greater than 6 months per year? □ Yes □ No
Do you prefer to be contacted by e-mail? □ No □ Yes: E-Mail _____________________________
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Parent category: Financial