Responsible Party Information
Spouse's Employment Information
If any income from sources other than full or part-time employment exists, please identify it below.
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)
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.
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.)
Do you have medical insurance?
Do you have a Health Savings Account or Flexible Spending Account?
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Attestation & Signature
I understand Medi-Lynx Cardiac Monitoring, LLC ("MediLynx") may verify the financial information contained in the Financial Assistance Application ("Application") in connection with MediLynx' evaluation of this Application, and by my electronic signature hereby authorize my employer or any individual listed on this Application to certify or provide additional detail with respect to the information provided in this Application. I certify that the statements made in this Application are true and correct, to the best of my knowledge and belief, and are made in good faith. I am aware that falsification or misrepresentation of information on this Application may result in denial of financial assistance.
Please use your mouse or a touchscreen device to sign the attestation below: