Billing and Financial Assistance Form Patient InformationAt the end of this form, please upload the following required documentation: • Federal Income Tax Return for the most recent tax year (Form 1040), including all applicable schedules • Most recent Wage and Tax Statements (Form W-2) and/or Miscellaneous Income (Form 1099) • Recent copy of the last 2 months of pay stubs with year-to-date earnings for each member of the household or a statement from the employer verifying gross wages • Proof of other income (i.e. rental property, etc.) • Recent copy of the last 2 months of bank statement of checking/savings accounts • Copy of valid Michigan driver’s license or Michigan state identification card • If applicable, a denial response from Medicaid, Marketplace, and/or COBRA documentation • Personal statement of financial need from the patient or responsible partyFirst name* Last name* Birth Date* Month Day Year Address* Street Address City State / Province / Region ZIP / Postal Code Social Security Number* Telephone*Email* Responsible Party InformationName and Address* Social Security Number* Telephone*Employer Name & Address* Telephone*Occupation* Employment Length* Monthly Salary* No. of Dependents* Driver’s License Number or State Issued Identification* Preferred Language* Spouse InformationName and Address Social Security Number TelephoneEmployer Name & Address TelephoneOccupation Employment Length Monthly Salary No. of Dependents Family Group Living in HomeName Relationship Age Name Relationship Age Name Relationship Age Name Relationship Age Name Relationship Age Health Insurance InformationInsurance Company* Ins Premium if applicable Suscriber Eligibility Date Policy & Group #s Did you apply for insurance through the Health Insurance Marketplace?* Yes No Please select reason enrollment was not completed and provide documentation* I did not qualify I cannot afford the premium I am exempt from penalties Other - please include letter of explanation with application Do you receive assistance with medical bills? (ie: Access Health, Amish, County Health Dept., Church, Indian Reservation, Sliding-fee Scale or Tencon)* Yes No Name/ID* Are you seeking medical services as a result of violent crime inflicted by another person?* Yes No Has a police report been filled?* Yes No Date of Accident* MM slash DD slash YYYY Are you seeking medical services due to an accident, motor vehicle or otherwise?* Yes No HiddenHas a police report been filled?* Yes No Do you have Auto Insurance?* Yes No Name of Auto Insurance* Provide Name of household member who has Auto Insurance* Have you filled a claim with your auto insurance?* Yes No Claim Number#* Adjustor Name* Assets/ExpensesResidence (Monthly Mortgage/Rent Payment)*Monthly Payment Residence (Monthly Mortgage/Rent Payment)*Value Residence (Monthly Mortgage/Rent Payment)*Unpaid Balance Second Residence / Vacation HomeMonthly Payment Second Residence / Vacation HomeValue Second Residence / Vacation HomeUnpaid Balance First Auto*Year / Make First Auto*Monthly Payment First Auto*Unpaid Balance Second AutoYear / Make Second AutoMonthly Payment Second AutoUnpaid Balance No Monthly Income (Patients with no income or expenses significantly exceeding income, please provide)*Name of person providing food, shelter and other living expenses Phone number*Phone number Relationship of applicant*Relationship of applicant Monthly Household Liabilities/Expenses*Rent / Mortgage, Balance Grocery Expense*Grocery Expense Child Care*Child Care Child Support / Alimony*Child Support / Alimony Utilities: Gas*Utilities: Gas Utilities: Electric*Utilities: Electric Utilities: Water/Sewer*Utilities: Water/Sewer Utilities: Other*Utilities: Other Telephone: (Mobile/Cell/Home etc.)*Telephone: (Mobile/Cell/Home etc.) Medication Expenses (co-pay / cash pay etc.)*Medication Expenses (co-pay / cash pay etc.) Unpaid Medical Expenses (i.e. doctor, dental, hospital, other providers) Please provide a detailed list with copies of most recent bills if available*Unpaid Medical Expenses (i.e. doctor, dental, hospital, other providers) Please provide a detailed list with copies of most recent bills if available Health Insurance Premiums*Health Insurance Premiums Car Loan Payments*Car Loan Payments Transportation (Bus, Taxi)*Transportation (Bus, Taxi) Loan Payment Type*Loan Payment Type Loan Payment Balance*Loan Payment Balance Credit Card Payment(s) Total Balance(s) Owed*Credit Card Payment(s) Total Balance(s) Owed Monthly IncomeTotal Household Income* Child Support* Alimony* Workers's compensation* Unemployment* Social Security / Disability* Unemployment Date / Length Rental Land Contract Divident / Interest Trust Fund Public Assistance* Retirement / Pension BANK* Location Upload a documentAccepted file types: pdf, docx, Max. file size: 1 MB. I understand this form must be completed in full and have all required documents attached when returned by me so Wayne Health can determine if I qualify for financial assistance. If it is not complete, I will receive a written notice that describes the additional information and/or documents required. I have provided true and accurate information, and I agree that Wayne Health may investigate this information.Applicant Date MM slash DD slash YYYY CAPTCHAUntitledNameThis field is for validation purposes and should be left unchanged.
