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Webinar Form – Covid Era
Rebooting from the COVID Era: Lessons Learned and Moving Forward
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Account Number
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Date of Birth
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Responsible Party Information
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Is the Responsible Party a citizen of the United States?
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Date of Birth
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Phone
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Email
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Employment Status
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Marital Status
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Employment Information
Employer Name
*
Employer Phone
Employment Type
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Hours Worked per Week
*
Income Amount
*
Frequency
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Hourly
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Bi-Weekly
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Spouse's Information
Spouse's Name
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Last
Spouse's Employment Status
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Spouse's Employment Information
Employer Name
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Employer Phone
Employment Type
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Part Time
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Hours Worked per Week
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Income Amount
*
Frequency
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Hourly
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Annually
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
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Weekly
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Semi-Monthly
Monthly
Annually
Source
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Alimony
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Structured Settlement
Pension / Retirement Fund
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Spouse's Non-Employment Income
Frequency
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Annually
Source
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Pension / Retirement Fund
Other
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)
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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
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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
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Do you have a Health Savings Account or Flexible Spending Account?
HSA or FSA
*
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No
Amount Available
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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.
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