MediLynx | William Moody

Responsible Party Information

Name *

First

Last

Is the Responsible Party a citizen of the United States? *

Yes
No

Date of Birth *//

Address *

Address Line 1

City

State

Zip Code

Phone *

Email *

Employment Status *

Marital Status *

Employment Information

Employer Name *

Employer Phone

Employment Type *

Hours Worked per Week *

Income Amount *

Frequency *

Spouse's Information

Spouse's Name *

First

Last

Spouse's Employment Status *

Spouse's Employment Information

Employer Name *

Employer Phone

Employment Type *

Hours Worked per Week *

Income Amount *

Frequency *

Non-Employment Income

If any income from sources other than full or part-time employment exists, please identify it below.

Patient's Non-Employment Income

Frequency *

Source *

Spouse's Non-Employment Income

Frequency *

Source *

Income Verification

Please provide income verification for all sources of household income. Acceptable documents include:

• Paycheck Remittance (3 mos.)	• Employer Verification	• IRS Form W-2
• Bank Statements (3 mos.)	• Determination Letters (Social Security, Workers Compensation, Unemployment)	• Governmental Assistance (FoodStamps, CDIC, Medicaid, TANF)
• Tax Return (most recent)

File Upload *

Click or drag a file to this area to upload.

Household Information

Please provide the total number of people in the patient's household. This number should only include the Patient/Responsible Party, Spouse, and Patient/Responsible Party's Dependents living within the same household.

Total Household Members *

Assets and Other Resources

Do you have any assets or other resources available to you?(Examples include savings accounts, trusts, stocks, bonds, retirement accounts, mutual funds, etc.)

Assets and Other Resources *

Yes
No

Amount Available *

Do you have medical insurance?

Medical Insurance *

Yes
No

Payor Name *

Do you have a Health Savings Account or Flexible Spending Account?

HSA or FSA *

Yes
No

Amount Available *

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Responsible Party Information

Employment Information

Spouse's Information

Spouse's Employment Information

Non-Employment Income

Income Verification

Household Information

Assets and Other Resources

Attestation & Signature

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Responsible Party Information

Employment Information

Spouse's Information

Spouse's Employment Information

Non-Employment Income

Income Verification

Household Information

Assets and Other Resources

Attestation & Signature