Financial Disclosure for Payment Assistance
Chicot Memorial Medical Center
2729 S. Hwy 65 & 82
Lake Village, Arkansas 71653
(870) 265-5351
1. GUARANTOR NAME:____________________________________________________
Address:________________________________________________________________
Telephone/message number:_________________________________________________
2.HOUSEHOLD MEMBERS:
Name (last,first) Birthdate Employer/School Social Security #
1._________________ _________ ______________ ______________
2._________________ _________ ______________ ______________
3._________________ _________ ______________ ______________
4._________________ _________ ______________ ______________
5._________________ _________ ______________ ______________
3.INCOME: LIST GROSS INCOME OF EACH HOUSEHOLD MEMBER:
(Copies of checks may be required/requested)
Present/Monthly Last 3 Months
Wages............................................ ____________________ __________________
Farm/Self-employment................... ____________________ __________________
State Assistance............................. ____________________ __________________
Social Security............................... ____________________ __________________
Unemployment Compensation........____________________ __________________
Workers’s Compensation............... ____________________ __________________
Alimony......................................... ____________________ __________________
Child Support................................ ____________________ __________________
Military Family Allotments............. ____________________ __________________
Pensions........................................ ____________________ __________________
Income from Dividends, Interests,
and Rent............................ ____________________ __________________
Other Income................................ ____________________ __________________
4.IF NO INCOME IS LISTED, HOW DO YOU LIVE?_____________________________
___________________________________________________________________
__________________________________________
5.YOUR EMPLOYER:_________________________________PHONE:______________
Address_________________________________________________________________
Occupation______________________________Years with company________________
If unemployed, date last worked:______________Estimated return to work:___________
SPOUSE’S EMPLOYER:______________________________PHONE:_____________
Address_________________________________________________________________
Occupation______________________________Years with company________________
If unemployed, date last worked:_____________Estimated return to work:____________
6.NEAREST RELATIVE NOT LIVING WITH YOU:_____________________________
Address:________________________________________________________________
Home Telephone:_________________________________________________________
7. LIST ALL HEALTH INSURANCE’S (need copies of cards):
Insured Name Company Name Insurance name/address Id#
1. __________________________________________________________________
2. __________________________________________________________________
3. __________________________________________________________________
4. __________________________________________________________________
8. IF NO INSURANCE, HAS THE PATIENT APPLIED FOR ASSISTANCE THROUGH MEDICAID?
No_____ Yes_____ Medicaid number:______________or attach copy of denial.
My signature below signifies that the information I have provided on this application is true and accurate.
I understand that falsification of information will invalidate this application.
______________________________________________ ________________________
Signature Date
Note: This agreement applies only to charges incurred at Chicot Memorial Medical Center.
Charges from your Physician, the Radiologist, or the Pathologist are not included or covered
by this agreement.
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(The following section to be completed by the Business Office)
Application has been reviewed and approved for charity care.
Application for charity care has been denied for the following reason:___________________________________________________________________________
___________________________________________________________________________
_______________________________________ ______________________________
Patient Account Representative Date
_______________________________________ ______________________________
Business Office Director Date
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