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 EASTSIDE ENDOSCOPY CENTER
FINANCIAL ASSISTANCE APPLICATION

 Medical Record Number:                                

PATIENT INFORMATION


Patient Name:                                                                                Birth Date:                                         

Marital Status (circle): S M D W        Last 4 Digits of SSN                                                  

Patient Address:                                                                                                                          

City/State/Zip:                                                                                                                 

Primary Phone: ________________________________ Alternate Phone:_______________________ 

Spouse’s Name: ______________________________ Spouse Primary Phone:                        

Medical Insurance:                                                                                                                       

Medical Insurance Application In Process*:                                                                               

RELATIVE/OTHER   CONTACT INFORMATION TO CONFIRM FINANCIAL SUPPORT

 Relative/Other Contact Name:                                                      Relationship:________________

Primary Phone:                                                     Alternate Phone: ________________________

EMPLOYMENT AND INCOME INFORMATION

Number of Taxable Dependents: _________Number of children Aged 18 and Under: __________

Patient’s employer(s):                                                                                                                  

Hire Date:                                                                                 Work Phone:                                      

Ave Hours Worked Weekly                                             Hourly Wage:                                     

Spouse’s employer(s):                                                                    Hire Date:                         

Ave Hours Worked Weekly                                             Hourly Wage:                                     

If you own a business or are self-employed, describe the business:

                                                                                                                                                      

*Uninsured patients may be denied full charity if they are determined to be “non-cooperative” with attempts to obtain insurance or eligibility coverage through other programs (for example - Medicaid).

EASTSIDE ENDOSCOPY CENTER

FINANCIAL ASSISTANCE APPLICATION

REQUIRED DOCUMENTATION & CERTIFICATION

In order to process your Financial Assistance Application, you must provide a copy of the following items:

        Copy of Official Picture Identification – Driver’s License or State ID or Valid Passport AND

        Income Verification – (i.e., Current Pay Stub; Tax Return; Bank Statement and Current Amount:

  • Alimony Received
  • Social Security Received
  • Unemployment Income
  • Disability Received

        Letter of Support – Signed by the party who is helping you with living and/or shelter support

CERTIFICATION

My signature on this form certifies that all the statements are true to the best of my knowledge and that I have disclosed all facts concerning my finances. I understand and acknowledge that any misrepresentation of my finances in connection with this Application, or any failure to cooperate with efforts to qualify me for programs which may cover the cost of my care (for example, Medicaid, personal injury claim, workmen’s compensation, auto claims) may invalidate any award of Financial Assistance/Charity Care and that I will be financially liable for the services provided. I agree to allow Eastside Endoscopy Center or its representatives to request and review a report of my credit and to take other reasonable steps to validate all information provided.

I understand that if I qualify for partial financial assistance/charity care I will be responsible for payment of the remaining portion of my bill.

Please Sign Below:

 

_______________________________________________________________

Print Patient Name / Guardian                                                                    (Date)

____________________________________________                                ______________

Signature Patient / Guardian                                                                       (Date)

             

   
   

Office Use ONLY

       

Vicky Mazza: _________________________________                               _____

       

FA Application Date: ____________________ FA     Application Term Date:                                   

       

Status: Approved/Denied       Decision     Date:__________

       

ACA discussed With Patient: Y/N   F/U Call Requested: Y/N    Best Time To Call _______________