Billing and Financial Assistance FormPatient 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 YearAddress* 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 AddressSocial Security NumberTelephoneEmployer Name & AddressTelephoneOccupationEmployment LengthMonthly SalaryNo. of DependentsFamily Group Living in HomeNameRelationshipAgeNameRelationshipAgeNameRelationshipAgeNameRelationshipAgeNameRelationshipAgeHealth Insurance InformationInsurance Company*Ins Premium if applicableSuscriberEligibility DatePolicy & Group #sDid you apply for insurance through the Health Insurance Marketplace?* Yes NoPlease 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 applicationDo you receive assistance with medical bills? (ie: Access Health, Amish, County Health Dept., Church, Indian Reservation, Sliding-fee Scale or Tencon)* Yes NoName/ID*Are you seeking medical services as a result of violent crime inflicted by another person?* Yes NoHas a police report been filled?* Yes NoDate of Accident* MM slash DD slash YYYY Are you seeking medical services due to an accident, motor vehicle or otherwise?* Yes NoHiddenHas a police report been filled?* Yes NoDo you have Auto Insurance?* Yes NoName of Auto Insurance*Provide Name of household member who has Auto Insurance*Have you filled a claim with your auto insurance?* Yes NoClaim Number#*Adjustor Name*Assets/ExpensesResidence (Monthly Mortgage/Rent Payment)*Monthly PaymentResidence (Monthly Mortgage/Rent Payment)*ValueResidence (Monthly Mortgage/Rent Payment)*Unpaid BalanceSecond Residence / Vacation HomeMonthly PaymentSecond Residence / Vacation HomeValueSecond Residence / Vacation HomeUnpaid BalanceFirst Auto*Year / MakeFirst Auto*Monthly PaymentFirst Auto*Unpaid BalanceSecond AutoYear / MakeSecond AutoMonthly PaymentSecond AutoUnpaid BalanceNo Monthly Income (Patients with no income or expenses significantly exceeding income, please provide)*Name of person providing food, shelter and other living expensesPhone number*Phone numberRelationship of applicant*Relationship of applicantMonthly Household Liabilities/Expenses*Rent / Mortgage, BalanceGrocery Expense*Grocery ExpenseChild Care*Child CareChild Support / Alimony*Child Support / AlimonyUtilities: Gas*Utilities: GasUtilities: Electric*Utilities: ElectricUtilities: Water/Sewer*Utilities: Water/SewerUtilities: Other*Utilities: OtherTelephone: (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 availableHealth Insurance Premiums*Health Insurance PremiumsCar Loan Payments*Car Loan PaymentsTransportation (Bus, Taxi)*Transportation (Bus, Taxi)Loan Payment Type*Loan Payment TypeLoan Payment Balance*Loan Payment BalanceCredit Card Payment(s) Total Balance(s) Owed*Credit Card Payment(s) Total Balance(s) OwedMonthly IncomeTotal Household Income*Child Support*Alimony*Workers's compensation*Unemployment*Social Security / Disability*Unemployment Date / LengthRentalLand ContractDivident / InterestTrust FundPublic Assistance*Retirement / PensionBANK*LocationUpload 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.ApplicantDate MM slash DD slash YYYY CAPTCHAUntitledEmailThis field is for validation purposes and should be left unchanged.
