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    Charity Care/Financial Assistance Application Form - confidential

    SCREENING INFORMATION

    Do you need an interpreter?

    If Yes, list preferred language:

    PLEASE NOTE

    • Although we cannot guarantee qualification for financial assistance, we strongly encourage you to apply and explore the option.

    • Within 21 calendar days after we receive your completed application and documentation, we will notify you if you qualify for assistance

    PATIENT AND APPLICANT INFORMATION

    Patient First Name

    Patient Middle Name

    Patient Last Name

    Gender:

    If other (may specify):

    Birth Date

    Person Responsible for Paying Bill

    Relationship to Patient

    Mailing Address:

    City

    State

    Zip Code

    Preferred Contact Method?

    Main Contact Number(s):

    Email Address:

    Please select if any of the following apply for the person responsible for paying the bill.

    If other, specify:

    Do you file taxes? (selecting no does not disqualify you from receiving financial assistance)

    Please select the following supports you need help with (select all that apply):

    If other, specify:

    FAMILY INFORMATION

    List all family members that the person responsible for paying the bill is financially responsible for. (All members will be included in the final determination.)

    Family size:

    Name

    Date of Birth

    Relationship to Patient

    If 18 Years or Older: Employer/Source of Income

    If 18 Years or Older: Total Gross Monthly Income

    INCOME INFORMATION

    All family members 18 years old or older must disclose their income. If you cannot provide documentation, you may submit a written signed statement describing your income. Please provide proof for every identified source of income.

    Please provide the following documents:

    • Documents used to verify income (if applicable):

    • Current Pay Stub with Year-to-Date Information

    • Social Security Award Letter

    • Veteran Award Letter

    • Retirement Statement

    • Unemployment Statement

  • Documents used to verify family size:

    • Most recently filed tax return (if applicable)

  • Additional information

    • Any additional information that you would like us to know about your financial situation such as a financial hardship, excessive medical expenses, seasonal or temporary income, personal loss, or information explaining no income.

    • If you have no proof of income or no income, please attach an additional page with an explanation.

    Please upload any available documents here. If unable to upload, please email them directly to patientaccounts@santiamhospital.org.

    PATIENT AGREEMENT

    I affirm that the above information is true and correct to the best of my knowledge. I understand if the financial information I give is determined to be false, the result may be denial of financial assistance, and I may be responsible for pay for services provided.