Financial Assistance Application

Prior to completing this application please read our Financial Assistance and Charity Care page.

The following items MUST be provided along with this application:

most recent tax return
the last three months of paycheck stubs or SSI/SSA/SSDI award letter
the three most recent checking/savings account statements
ID card
Social Security Card

If you or your spouse report a $0 income, please prepare a written explanation for each unemployed individual of how your household is meeting basic needs. The written explanation must include former employer, last date worked, living situation, job search/disability status, signature, and date. An example form can be provided by the Patient Financial Counselor. You must provide three letters from non-family members explaining that you receive no income and how are meeting/supporting your household with basic day to day needs.

***If someone is assisting you with income/money, we will need a signed letter of support.***

Financial Assistance Information

Patient Information

First Name

Last Name

Social Security Number

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Spouse's Information

First Name

Last Name

Spouse's Social Security Number

Spouse's Date of Birth

YYYY

Spouse's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Spouse's Phone Number

(###)

###

####

Employment Information

Employer Name

Employer's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer's Phone Number

(###)

###

####

Number of Hours Worked Weekly

$ Paid Per Hour

Job Title

Spouse's Employer

Spouse's Employer's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Spouse's Employer Phone Number

(###)

###

####

Spouse's Number of Hours Worked Weekly

Spouse's $ Paid Per Hour

Spouse's Job Title

Additional Household Members:

Name

First Name

Last Name

Age

Date of Birth

YYYY

Relationship

Name

First Name

Last Name

Age

Date of Birth

YYYY

Relationship

Name

First Name

Last Name

Age

Date of Birth

YYYY

Relationship

Name

First Name

Last Name

Age

Date of Birth

YYYY

Relationship

Name

First Name

Last Name

Age

Date of Birth

YYYY

Relationship

Name

First Name

Last Name

Age

Date of Birth

YYYY

Relationship

Additional Income Information:

2nd Job

Yes

Income from 2nd Job

Small Business

Yes

Income from Small Business

Income from ANY Other Source:

(ex. Child Support, other Governmental Aid)

Are any third parties potentially liable for your medical expenses?

(ex. auto insurance, workers' compensation, lawsuit)

Yes

I certify that I am unable to pay for all the costs of necessary services and that the information I have given to Sevier County Medical Center is true and accurate. I understand that Sevier County Medical Center will use this information to determine my eligibility for financial assistance. I have disclosed all my assets and income. Failure to report assets or income could result in legal recourse, including criminal charges. I agree to report any changes in my financial status to Sevier County Medical Center. I authorize Sevier County Medical Center, or any credit reporting agency, to investigate any reference, statements, employment, or other data given by me or any other person pertaining to my credit and financial responsibility.

Signature

Date

YYYY

Spouse's Signature

Date

YYYY