Financial Statement Form - DOC

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					                                                                  Rush University Medical Center




        REQUEST FOR DETERMINATION OF ELIGIBILITY FOR
    FINANCIAL ASSISTANCE PROGRAM: FINANCIAL STATEMENT
I hereby request that Rush University Medical Center evaluates the following financial
information in regards to my possible eligibility for a Financial Assistance Program for
hospital-based services (non-professional fees) through the Medical Center.
I understand that the information I provide concerning the annual income and size of my
household is subject to verification by the Medical Center. I also understand that if any
portion of the information I have provided is determined to be falsified, I will be
responsible for all medical expenses incurred at this institution.

   1) Demographic Information

      NAME:        _______________________________________________________
                       Last                            First                   Middle Int.

      ADDRESS: _______________________________________________________
                       Number and Street                                       Apt.

                   ______________________________________________________
                       City                                    State           Zip Code
      PHONE:       (          ) _________________________
2) Employment Information

      OCCUPATION: __________________________________________________

       EMPLOYER: ________________________ PHONE: (                  ) ____________
                    * If not employed, date last worked ____/____/____
3) Income Information
       - Please enclose your most recent W-2 forms, Income Tax Return,
         or Unemployment/Social Security statements (past 3 months)
                              TOTAL (past 3 months)          TOTAL (past 12 months)
 Wages Earned                    _______________            _______________
 Public Assistance               _______________            _______________
 Social Security                 _______________            _______________
 Unemployment Comp               _______________            _______________
 Workmen’s Compensation          _______________            _______________
 Strike Benefits                 _______________            _______________
 Alimony Received                _______________            _______________
 Child Support Received          _______________            _______________
 Military Family Allotments      _______________            _______________
 Pensions                        _______________            _______________
 Income from:
     Dividends                   _______________            _______________
     Interest                    _______________            _______________
     Rent                        _______________            _______________
 Other                           _______________            _______________
                                           Page 1
                                                                 Rush University Medical Center




4) Family Size Information


      Total Number in Household*:        __________
             (*Number of individuals for whom you are financially responsible)

      Name                                             Age            Relationship

      ______________________________                   _____          ____________

      ______________________________                   _____          ____________

      ______________________________                   _____          ____________

      ______________________________                   _____          ____________

      ______________________________                   _____          ____________

      ______________________________                   _____          ____________

      ______________________________                   _____          ____________


5) Type of Medical Service(s) Provided:

                                    ___________________________________

                                    ___________________________________




      I affirm that the information that has been provided in this Financial Statement is
      true and correct to the best of my knowledge.


      _____________________________________                    ____/____/____
      Signature of Person Making Request                           Date



      _____________________________________                    ____/____/____
      Rush Financial Counselor/Representative                      Date



                                      Page 2
                                                                       Rush University Medical Center


FOR OFFICE USE ONLY:

Determination of Eligibility

1) INCOME
    Total income for last 3 months $______________ X 4 = $_____________

       Total income for last 12 months                                $ _____________

2) If the patient’s statement of income was verified by the time the decision was
   determined, state what information was used along with the source (name and
   telephone number) of the person/company providing the information.
   Last year’s Income Tax Return
    Pay Stub
    Other-______________________________________________________

         Patient is eligible for COBRA                Yes      No
         Patient is covered by insurance:             Yes      No
         Patient lives in Catchment Area                    Yes     No
         Search America Recommendation:                AcceptedDenied
         Admission Source:               Scheduled       ED     RTS Transfer
         CEA reviewed account. Determined ineligible for MANG. Yes No
         Number of visits to Rush ________.
         Previous participant of Financial Assistance Programs? Yes No
         Diagnosis _____________________________________________________
         Procedure_____________________________________________________
3) The applicant is:
 Eligible                                        Estimated/Exact Discount of      $___________
 Ineligible
4) If Financial Assistance is denied, state the reason why the patient is ineligible:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

5) Signatures

_____________________________________________                       ____/____/____
Signature of person making eligibility determination                        Date

_____________________________________________                       ____/____/____
Director, Patient Access                                                    Date

_____________________________________________                       ____/____/____
VP, Healthcare Finance                                                      Date
                                              Page 3

				
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