Online Application "*" indicates required fields Welcome to your Memorial Health System online financial assistance application! This application normally takes 10 minutes or less to complete. Thank you in advance and we appreciate your time. In order to process your application, we need supporting documents to verify your financial situation. Required documents include any of the following that apply to your household: Pay Stubs (3 months prior to hospital service) Any other documentation containing income information (3 months prior to hospital service) Bank Statements for Checking and Savings Accounts (3 months prior to hospital service) After reviewing your submitted application, we may reach out to assist you with additional programs and insurance options available to you. Please get an electronic copy or pictures of your documents ready before starting your application. If you submit an incomplete application, we will reach out to you via mail for any additional information or documentation needed to process your application. An incomplete application or missing documents may lead to your application being denied. Patient Name* First Middle Initial Last Patient's Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient's Phone NumberAccount or Statement NumberDate of Service (MM/YYYY)Patient's Date of Birth*Patient’s Source of Income or Employer Name (If Applicable)Income includes employment/wages, self-employment, unemployment, Social Security, retirement distributions, etc.What was the patient's gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was the patient's gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Has the patient received income from any other sources? Yes No Patient's 2nd Source of Income or Employer NameWhat was the patient's 2nd gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was the patient's 2nd gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.* Including yourself, what is the total number of people in your family?*“Family” is defined as the responsible party, the responsible party’s spouse (if applicable), and all of their natural or adoptive children under 18 who live in their home.Please enter a number from 1 to 7.Additional Family Member 1 – Name* First Last Additional Family Member 1 – Date of Birth*Additional Family Member 1 – Relationship to Patient*Select RelationParentSpouseChildSiblingGuardianNone of the AboveAdditional Family Member 1 – Source of Income or Employer Name (If Applicable)Income includes employment/wages, self-employment, unemployment, Social Security, retirement distributions, etc.What was Additional Family Member 1's gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 1's gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Has Additional Family Member 1 received income from any other sources? Yes No Additional Family Member 1 – 2nd Source of Income or Employer NameWhat was Additional Family Member 1's – 2nd gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 1's – 2nd gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Family Member 2 – Name* First Last Additional Family Member 2 – Date of Birth*Additional Family Member 2 – Relationship to Patient*Select RelationParentSpouseChildSiblingGuardianNone of the AboveAdditional Family Member 2 – Source of Income or Employer Name (If Applicable)Income includes employment/wages, self-employment, unemployment, Social Security, retirement distributions, etc.What was Additional Family Member 2's gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 2's gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Has Additional Family Member 2 received income from any other sources? Yes No Additional Family Member 2 – 2nd Source of Income or Employer NameWhat was Additional Family Member 2's – 2nd gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 2's – 2nd gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Family Member 3 – Name* First Last Additional Family Member 3 – Date of Birth*Additional Family Member 3 – Relationship to Patient*Select RelationParentSpouseChildSiblingGuardianNone of the AboveAdditional Family Member 3 – Source of Income or Employer Name (If Applicable)Income includes employment/wages, self-employment, unemployment, Social Security, retirement distributions, etc.What was Additional Family Member 3's gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 3's gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Has Additional Family Member 3 received income from any other sources? Yes No Additional Family Member 3 – 2nd Source of Income or Employer NameWhat was Additional Family Member 3's – 2nd gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 3's – 2nd gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Family Member 4 – Name* First Last Additional Family Member 4 – Date of Birth*Additional Family Member 4 – Relationship to Patient*Select RelationParentSpouseChildSiblingGuardianNone of the AboveAdditional Family Member 4 – Source of Income or Employer Name (If Applicable)Income includes employment/wages, self-employment, unemployment, Social Security, retirement distributions, etc.What was Additional Family Member 4's gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 4's gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Has Additional Family Member 4 received income from any other sources? Yes No Additional Family Member 4 – 2nd Source of Income or Employer NameWhat was Additional Family Member 4's – 2nd gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 4's – 2nd gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Family Member 5 – Name* First Last Additional Family Member 5 – Date of Birth*Additional Family Member 5 – Relationship to Patient*Select RelationParentSpouseChildSiblingGuardianNone of the AboveAdditional Family Member 5 – Source of Income or Employer Name (If Applicable)Income includes employment/wages, self-employment, unemployment, Social Security, retirement distributions, etc.What was Additional Family Member 5's gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 5's gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Has Additional Family Member 5 received income from any other sources? Yes No Additional Family Member 5 – 2nd Source of Income or Employer NameWhat was Additional Family Member 5's – 2nd gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 5's – 2nd gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Additional Family Member 6 – Name* First Last Additional Family Member 6 – Date of Birth*Additional Family Member 6 – Relationship to Patient*Select RelationParentSpouseChildSiblingGuardianNone of the AboveAdditional Family Member 6 – Source of Income or Employer Name (If Applicable)Income includes employment/wages, self-employment, unemployment, Social Security, retirement distributions, etc.What was Additional Family Member 6's gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 6's gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*Has Additional Family Member 6 received income from any other sources? Yes No Additional Family Member 6 – 2nd Source of Income or Employer NameWhat was Additional Family Member 6's – 2nd gross income (before taxes) for 3 months prior to the date of service? If none, enter 0.*What was Additional Family Member 6's – 2nd gross income (before taxes) for 12 months prior to the date of service? If none, enter 0.*If you report $0 income, please provide an explanation for how you were being supported. Did you have health insurance covering these services?* Yes No Insurance Company NameInsurance Member IDInsurance Group NumberSubscriber NameWas the patient a resident of Ohio at the time of service?* Yes No Was the patient an active Medicaid recipient at the time of service?* Yes No If yes, enter recipient billing number.Are these services a result of a motor vehicle accident?* Yes No Household Income Sources Please check all that apply for all household members. “Household” is defined as the responsible party, the responsible party’s spouse (if applicable), and all of their natural or adoptive children under 18 who live in their home. Income Sources Wages Social Security Veterans Benefits SSI – Disability Railroad Benefits Self-Employment Income Retirement/Pension Benefits Child Support or Alimony Unemployment Compensation Rental Income Fundraisers (GoFund Me, ETC) Dividends/Interest/Royalties Military Family Allotments Estates/Trusts IRA/401K/401B Annuity Payments Workers Compensation Residential Foster Care Other Household Asset(s) Information Please provide the total balance for all household members in the following categories. If none, enter 0. “Household” is defined as the responsible party, the responsible party’s spouse (if applicable), and all of their natural or adoptive children under 18 who live in their home. Checking Account Balance*Savings Account Balance*Stock/Bonds/Certificate of Deposits (CD)*Trust Fund Balance*Cash*Other* Uploading Documents Please use the drop boxes below to submit income verification documents with this application. WagesPlease upload Wages documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Social SecurityPlease upload Social Security documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Veterans BenefitsPlease upload Veterans Benefits documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. SSI – DisabilityPlease upload SSI – Disability documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Railroad BenefitsPlease upload Railroad Benefits documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Self-Employment IncomePlease upload Self-Employment Income documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Retirement/Pension BenefitsPlease upload Retirement/Pension Benefits documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Child Support or AlimonyPlease upload Child Support or Alimony documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Unemployment CompensationPlease upload Unemployment Compensation documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Rental IncomePlease upload Rental Income documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Fundraisers (GoFund Me, ETC)Please upload Fundraisers (GoFund Me, ETC) documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Dividends/Interest/RoyaltiesPlease upload Dividends/Interest/Royalties documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Military Family AllotmentsPlease upload Military Family Allotments documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Estates/TrustsPlease upload Estates/Trusts documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. IRA/401K/401B Annuity PaymentsPlease upload IRA/401K/401B Annuity Payments documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Workers CompensationPlease upload Workers Compensation documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Residential Foster CarePlease upload Residential Foster Care documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Other Income DocumentationPlease upload any Other Income documentation from 3 months prior to the hospital service. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Bank Statements for Checking and Savings AccountsPlease upload your bank statements from 3 months prior to the hospital service for your checking and savings accounts, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Medical Insurance and/or Medicaid Card – Front & BackPlease attach pictures or copies of the front and back of your medical insurance or Medicaid card effective at the time of service, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. This field is hidden when viewing the formTotal Family 3 Month IncomeThis field is hidden when viewing the formTotal Family 12 Month IncomeThis field is hidden when viewing the formTotal Family 2nd – 3 Month IncomeThis field is hidden when viewing the formTotal Family 2nd – 12 Month IncomeThis field is hidden when viewing the formTotal Family 12 Month IncomeThis field is hidden when viewing the formNumberThis field is hidden when viewing the formFamily AdditionalsThis field is hidden when viewing the formTotal Family SizeThis field is hidden when viewing the formFamily Additional Total 5380This field is hidden when viewing the formYearly Rate 15060This field is hidden when viewing the formTotal 3 Month Income Div by 3This field is hidden when viewing the formCalculated % FPL 3 MonthsThis field is hidden when viewing the formTotal 12 Month Income Div by 12This field is hidden when viewing the formCalculated % FPL 12 MonthsApplicant Signature* Incomplete applications without income verification, checking and savings documentation will be returned to the applicant and denied until returned complete. I understand that this application is made so that the hospital can see if I am eligible for HCAP or financial assistance based on the defined criteria. If any information I have given proves to be untrue, I understand that the hospital may re-check my financial status and take whatever action is appropriate. Are You Ready to Submit Your Application?* No I’m Ready On a scale from 1-5, with 1 being HARD and 5 being EASY, how was your experience applying for Financial Assistance online?Please enter a number from 1 to 5.Great! Please do not close your browser or leave this page until you see the confirmation page.CommentsThis field is for validation purposes and should be left unchanged.
