Responsible Party 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?