Financial Assistance Application

Please complete ALL fields of the application.
Navigate through the application by using the tab key.
(Do not press the enter key because it submits your application incomplete)
Click the submit button when you have completed the entire application.

Please Complete All Fields

Personal Information
 
First Name:
 
Last Name:
 
Phone Number:
 
Email Address:
 
Address:
 
City/State/Zip: ,
 
Number of Family Members in the Home:   
 
Employer:
 
 
Income
       
Patient's Gross Income:
Previous Year: Last 3 Months:
       
Other Family Income:
Previous Year: Last 3 Months:
       
Total Family Income:
Previous Year: Last 3 Months:
 
 
Assets
       
Savings / Checking:
 
Stocks / Bonds:
 
Additional Vehicle:
 
Other Real Estate:
 
 
Terms and Conditions
 
I certify that the above information is true and accurate to the best of my knowledge. Further, I have exhausted all efforts to obtain coverage from all federal, state, and local programs, such as Medicaid, Vocational Rehab, etc.
 
I understand this application is made so the hospital can determine my eligibility for uncompensated services. HCMH reserves the right to reverse the uncompensated services decision if the information provided is found to be false. I agree to allow HCMH to access my credit history.
 
Check Yes if You Agree to the Terms and Conditions mentioned above. YES
 
 
For more information to discuss your application or to set up an appointment, please contact HCMH Business Services by phone at 336-527-7095 to speak with a HCMH Financial Counselor.