Wakemed Financial Statement

ADVERTISEMENT

WakeMed
Financial Statement
Return Completed form to: ___________________
Phone number for questions: (919) 350-8359
Account Number
Medical Record
Guarantor Information
Patient Information
Spouse Information
Name:
Name:
Name:
SS#:
SS#
SS#:
DOB:
DOB:
DOB:
How long at this address?
Guarantor
Address
What county do you live in?
How long at this address?
Patient
Address
What county do you live in?
Where do you file your taxes?
US Citizen?
__ Yes
__ No
Marital Status
Single
Separated
Married
Divorced
Health Insurance/ Other Assistance
Are you covered by any of the following? (Check all that apply)
Medicare
Medicaid
Health Ins
Cancer Program
Blind Comm
Other
Veteran’s Admin
Sickle Cell
Cripple Children
Voc Rehab
Migrant Hlth
Have you applied for Medicaid?
If yes, when:
What County?
Caseworker’s
Food Stamps
__Yes
__No
Name:
Employment History (Attach additional documentation if necessary)
Patient or Guarantor’s employer:
From:
To:
Salary
Hr/Wk/Mo/Yr
Average # of hrs worked per week:
Phone #:
Prior Employer’s Name:
From:
To:
Salary
Hr/Wk/Mo/Yr
Average # of hrs worked per week:
Phone #:
Spouse’s Employer:
From:
To:
Salary
Hr/Wk/Mo/Yr
Average # of hrs worked per week:
Phone #:
Prior Employer’s Name:
From:
To:
Salary
Hr/Wk/Mo/Yr
Average # of hrs worked per week:
Phone #:

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go
Page of 2