Date
Account #
Monroe Clinic Financial Statement Please select which Financial Assistance Program you’re applying for: Community Care _______
Payment Agreement _______
Patient Information Telephone No:
Patient Name:
DoB:
Present Home Address:
How long:
Previous Address:
Social Security No or ITIN:
Marital Status:
If separated, How Long?
Employer Name and Address:
Do you use any other names?: How Long:
VA Benefits:
If pregnant, Due Date:
How long employed?
Employer Name and Address (if applicable): Any other Medical coverage? Name:
DoB:
Present Home Address:
How long:
Claimed as dependent?
Is Medical Insurance offered?
How long employed? Members Cost of Coverage: $ Spouse Information Telephone No: Do you use any other names?: Previous Address:
How long:
VA benefits:
Social Security No or ITIN:
Claimed as dependent?
If pregnant, Due Date:
Employer Name and Address:
How long employed?
Employer Name and Address (if applicable): Any other Medical coverage?
Dependents
DoB
How long employed? Members Cost of Coverage: $ Dependent Information Does child Parent not in US Citizen? live with you? household?
Is Medical Insurance offered?
Do you receive financial assistance? From whom?
Current Coverage
MONTHLY INCOME Items Gross Income (Before Taxes) Student Grants Social Security Interest/Dividends Rental Income Alimony/Child Support Unemployment Cash Jobs Food Stamps Pensions Disability Worker's Compensation VA Benefits Other
ASSETS
Applicant
Spouse
Other
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
BALANCE/VALUE
Checking Accounts
Savings Accounts HSA Accounts CD, IRA, 401(k), Money Market, Pension, Etc.
Life Insurance Stocks, Bonds and Mutual Funds
Automobiles/Trucks
Other Assets: Boats, Motorcycles, RV, etc.
Home Value: # Acres on Homestead and Land Value Other Real Estate and Value
Total
$
$
$
Other Assets: Livestock, Machinery, etc. Total
$ $
MONTHLY EXPENSES Item
Monthly Payment
Items
OTHER EXPENSES Monthly Payments Balances
Rent/Mortgage
$
Charge Accounts
$
$
Electricity
$
$
$
Gas/Propane
$
$
$
Water/Sewer/Garbage $
$
$
Telephone
$
$
$
Cable/Internet
$
$
$
Food
$
$
$
Medicine
$
$
$
Other Real Estate Loans
$
$
Student Loans
$
$
Miscellaneous
$
$
Personal Loans Automobile Loans Real Estate Loans - Home
Baby Sitter
$
Transportation Alimony/Child Support
$
Auto Insurance
$
Home Insurance
$
Life Insurance
$
Health Insurance
$
$
Personal Property Tax
Total Monthly Income $ Total Monthly Expenses
Sub Total
$
If you are accepted into the Community Care program, you will be required to select a Primary Care Provider from Family Medicine in either our Monroe, Brodhead or Freeport locations. Please indicate which site would be your preferred choice:
_____ Monroe, WI
_____Brodhead, WI
_____Freeport, IL
Patient Agreement The undersigned applies for financial assistance indicated in this application and represents that all statements made in this application are true and are made for the purpose of obtaining financial assistance for Monroe Clinic services. The undersigned also agrees to allow this facility to contact any or all references for verification including credit bureaus. Proof of income will accompany this application or be provided within ten days after application date. If not received in the allotted time I understand my request for Community Care will be denied. I also understand that if the information which I submit is determined to be false, such a determination will result in a denial of providing services as uncompensated services, and that I will be liable for charges for services provided.
Signature of Applicant/Responsible Party: Date of Application: Signature of person accepting application:
Optional: I also authorize______________________________, who is my _____________________________ to discuss my application status with any member of the Community Service Staff.
Phone No:_____________________
Initial _____________
Date
Financial Assistance Checklist Thank you for your interest in Monroe Clinic’s financial assistance programs. In order to complete your application for financial assistance, we request that you provide the following items prior to your appointment with your Patient Financial Counselor. It’s important that you provide all of this information because your application cannot be processed until the following items have been received.
Financial statement completed and signed: Last year’s Federal Taxes including all tax schedules (if applicable) or IRS form 4506-T Complete copies of your last 3 months bank statements showing savings and checking activity Proof of value for any Health Savings Accounts (HSA) Last 3 month’s pay stubs / unemployment statement Social security or disability income benefits statement Proof of any alimony/child support income received Proof of any income received in the last 3 months from student grants, pension, retirement, stocks, interest, rent, etc. If self-employed, proof of business income and expenses for last 3 months If self-employed, do you take a draw or does your business pay personal expenses? Please provide proof Proof of application for Medical Assistance in the county where you reside (current approval or denial letter) Apply for Wisconsin or Illinois Well Woman program or Family Planning (if applicable) Support letter including signature, printed name, address and phone number (if anyone helps you financially) Proof of value for all financial assets, including 401(k), pension, retirement, stocks, bonds, CD, IRA, mutual funds, money markets, etc. Proof of value for any real estate owned (other than your home). Please include proof of any debt owed on property Set up and adhere to a monthly payment plan Documentation of any health insurance premium you currently pay If medical insurance is offered to you through an employer, proof of cost of the insurance and when you would be eligible for coverage **ALL INFORMATION ON ANY CHECKED ITEMS MUST BE RETURNED TO MONROE CLINIC PATIENT ACCOUNTS DEPARTMENT WITHIN 10 BUSINESS DAYS OR YOUR APPLICATION WILL BE AUTOMATICALLY DECLINED** If you have questions about any item on this page, please contact your Patient Financial Counselor: Patient Financial Counselor:
Telephone
E-mail
Responsible for:
Lorri Larson
608-324-2276
[email protected]
Last names A-G
Stephanie Kruse
608-324-1259
[email protected]
Last names H-N
Laurie Seffrood
608-324-2293
[email protected]
Last names O-Z
Fax
608-324-1629
N/A
N/A
