Wayne Health

Patient Information

At 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 party

First name*

Last name*

Birth Date*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Social Security Number*

Telephone*

Email*

Responsible Party Information

Name 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 Information

Name and Address

Social Security Number

Telephone

Employer Name & Address

Telephone

Occupation

Employment Length

Monthly Salary

No. of Dependents

Family Group Living in Home

Name

Relationship

Age

Name

Relationship

Age

Name

Relationship

Age

Name

Relationship

Age

Name

Relationship

Age

Health Insurance Information

Insurance Company*

Ins Premium if applicable

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*

Are you seeking medical services due to an accident, motor vehicle or otherwise?*

Yes
No

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Has 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/Expenses

Residence (Monthly Mortgage/Rent Payment)*

Monthly Payment

Residence (Monthly Mortgage/Rent Payment)*

Value

Residence (Monthly Mortgage/Rent Payment)*

Unpaid Balance

Second Residence / Vacation Home

Monthly Payment

Second Residence / Vacation Home

Value

Second Residence / Vacation Home

Unpaid Balance

First Auto*

Year / Make

First Auto*

Monthly Payment

First Auto*

Unpaid Balance

Second Auto

Year / Make

Second Auto

Monthly Payment

Second Auto

Unpaid 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

Relationship of applicant

Monthly Household Liabilities/Expenses*

Rent / Mortgage, Balance

Grocery Expense

Child Care

Child Support / Alimony

Utilities: Gas

Utilities: Electric

Utilities: Water/Sewer

Utilities: Other

Telephone: (Mobile/Cell/Home 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

Health Insurance Premiums

Car Loan Payments

Transportation (Bus, Taxi)

Loan Payment Type

Loan Payment Balance

Credit Card Payment(s) Total Balance(s) Owed

Monthly Income

Total 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 document

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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

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Comments

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Billing and Financial Assistance Form

Patient Information

Responsible Party Information

Spouse Information

Family Group Living in Home

Health Insurance Information

Assets/Expenses

Monthly Income