Online Application "*" indicates required fields CommentsThis field is for validation purposes and should be left unchanged.Welcome to your ABC Hospital online financial assistance application! In order to process your application, we need supporting documents to verify your financial situation. Required documents include: Copy of your last two pay stubs or last year’s W-2 formCopy of your most recent tax returnAfter reviewing your submitted application, we may reach out to assist you with additional program and insurance options available to you or request additional documentation. Please get an electronic copy or pictures of your documents ready before starting your application. If you submit an incomplete application, we will reach out to you for any additional information or documentation needed to process your application. Do you have your proof of income documents ready?* Yes No I will mail in or drop off my proof of income documents at ABC Hospital in the next 10 days.*The address to send your documents to is: ABC Hospital, 123 Hospital Way, Traverse City, MI 49686 Yes Applicant InformationName* First Last Date of Birth*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Additional Household InformationIncluding yourself, what is the total number of people living in your household?*Please enter a number from 1 to 10.Additional Household Member 1Name First Last Date of BirthRelationship to ApplicantAdditional Household Member 2Name First Last Date of BirthRelationship to ApplicantAdditional Household Member 3Name First Last Date of BirthRelationship to ApplicantAdditional Household Member 4Name First Last Date of BirthRelationship to ApplicantAdditional Household Member 5Name First Last Date of BirthRelationship to ApplicantAdditional Household Member 6Name First Last Date of BirthRelationship to ApplicantAdditional Household Member 7Name First Last Date of BirthRelationship to Applicant Financial InformationDo you or any members of your household receive income from any sources?* Yes No Applicant – Financial InformationWhat is your current monthly gross employment income?*What is your current monthly gross income from all other sources?*Spouse/Other – Financial Information (if applicable)What is your current monthly gross employment income?What is your current monthly gross income from all other sources?If no, please explain how you are being supported financially.* Insurance InformationAt your service date did you have any plan, group or insurance that reimburses medical expenses?* Yes No Insurance Company NameInsurance Group NumberInsurance Member ID Uploading Documents This section is for attaching the documents we need to fully process your application and verify the information you provided.Proof of IncomePlease provide proof of income: A copy of your W-2, or payroll stub. Drop files here or Select files Max. file size: 50 MB, Max. files: 10. Medical Insurance and/or Medicaid Card – Front & BackPlease attach pictures or copies of the front and back of your medical insurance or Medicaid card effective at the time of service, if applicable. Drop files here or Select files Max. file size: 50 MB, Max. files: 10. This field is hidden when viewing the formNumberThis field is hidden when viewing the formFamily AdditionalsThis field is hidden when viewing the formTotal Family SizeThis field is hidden when viewing the formFamily Additional Total 4720This field is hidden when viewing the formYearly Rate 13590This field is hidden when viewing the formTotal 12 Month Income Div by 12This field is hidden when viewing the formCalculated % FPL 12 MonthsSignature*I certify that the information in this application is true and correct to the best of my knowledge. I will apply for any state, federal or local assistance for which I may be eligible to help pay for this medical bill(s). I understand that the information provided may be verified, and I authorize ABC Hospital to contact third parties to verify the accuracy of the information provided in this application. I understand that if I knowingly provide untrue information in this application, I will be ineligible for financial assistance, any financial assistance granted to me may be reversed, and I will be responsible for the payment of the medical bill(s). I grant ABC Hospital permission to contact me using any method provided on this application.Your NameYour NameYour NameYour Name Are You Ready to Submit Your Application?* No I’m Ready On a scale from 1-5, with 1 being HARD and 5 being EASY, how was your experience applying for Financial Assistance online?Please enter a number from 1 to 5.Great! Please do not close your browser or leave this page until you see the confirmation page.
