Family Information

List family members in your household, including you. "Family" includes people related by birth, marriage, or adoption who live together.

Note: All adult family member income must be disclosed. Sources of income include, for example: wages, unemployment, self-employment, worker's compensation, disability, SSI, child/spousal support, work study progragms (students), pension, retirement account distributions, other (please explain).

Family member 1 should be you.

Family Member Name 1 *

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?

Yes

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

Yes

Family Member Name 4

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 5

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 6

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

Expense Information

We use this information to get a more complete picture of your financial situation.

Monthly household expenses

Rent/mortgage *

Medical expenses *

Insurance Premiums *

Utilities *

Other Debt/Expenses

(child support, loans, medications, other)

Asset Information

This informataion may be used if your income is above 101% of the Federal Poverty Guidelines.

Current checking account balance *

Current savings account balance *

Additional Information

Please add any additional information if there is other information about your current financial situation that you would like us to know, such as financial hardship, excessive medical expenses, seasonal or temporary income, or personal loss.

Enter additional information

You must include proof of income with your application

All family members 18 years or older must disclose their income. If you cannot provide documentation, you may submit a written signed statement describing your income. Please provide proof for every identified source of income. The more documentation you provide, the more accurately we can calculate any potential discount.

Examples of proof of inclome include:
-Current pay stubs (3 most recent) OR

-Annual SSA/SSI letter or bank statement, OR
-Written, signed statements from employers or others, OR

-Approval/denial of eligibility for Medicaid and/or state-funded medical assistance, OR

-Approval/denial of eligibility for unemployment compensation, OR

-If you have no proof of income or no income, please attache an additional page with an explanation.

NOTE: Last year's income tax return, including schedules, if applicable, may be requested for additional verification.

Attach file 1

Attache file 2

Attach file 3

Attach file 4

Attach file 5

Attach file 6

Attach file 7

Attach file 8

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

Signature of person applying

Clear

Date signed

Once completed, please SUBMIT your application for review.