Patient and applicant information

Patient First Name *

Patient Middle Name *

Patient Last Name *

Gender

Male

Female

Date of birth

Patient Social Security Number (optional*)

*optional, but needed for more generous assistance above state law requirements

Person Responsible for Paying Bill

Person Responsible Birth Date

Relationship to Patient

Social Security Number (optional*)

Address

City

State

Postal code

Main Contact Numbers *

Email *

Date of Hire

How long unemployed? (years)

Do you have any form of prescription drug insurance?

Yes

Healthcare provider name

If you have Medicare, please provide your Medicare Beneficiary Number (MBI) number found on your Medicare card

Family Information

Family Member Name

Date of Birth

Relationship to Patient

If 18 years old or older: Employer(s) name or source of income

If 18 years old or older: Total gross monthly income (before taxes)

Also applying for financial assistance?

Yes

Do you want to add another family member's details?

Yes

Family Member Name 2

Date of Birth

Relationship to Patient

If 18 years old or older: Employer(s) name or source of income

If 18 years old or older: Total gross monthly income (before taxes)

Also applying for financial assistance?

Yes

Do you want to add another family member's details?

Yes

Family Member Name 3

Date of Birth

Relationship to Patient

If 18 years old or older: Employer(s) name or source of income

If 18 years old or older: Total gross monthly income (before taxes)

Also applying for financial assistance?

Expense Information

Rent/mortgage

Other Debt/Expenses

Insurance Premiums

Medical expenses

Utilities

Asset Information

Current checking account balance

Current savings account balance

Attach Files Here

Patient Agreement

I understand that Reedsburg Area Medical Center may verify information by reviewing credit information and obtaining
information from other sources to assist in determining eligibility for financial assistance or payment plans.

I affirm that the above information is true and correct to the best of my knowledge. I understand if the financial information I
give is determined to be false, the result may be denial of financial assistance, and I may be responsible for and expected to pay for