Financial Assessment Application

Consistent with the Cullman Regional Medical Center mission to promote wellness and provide excellent healthcare services in the most efficient manner, CRMC offers charity applications to patients who lack the ability to pay and are willing to submit supporting documentation.

Following the financial screening and collections process, patients who demonstrate a lack of ability to pay will be offered this Financial Assistance Application. This excludes bad debt accounts. 

Complete the application entirely. A patient is allowed ten (10) days from receipt to submit the application and return the supporting documents. Additional time will be granted for patients who request it for extenuating circumstances. 

Return all documentation that applies to your HOUSEHOLD:
* Most recent year's Income Tax Return (completed return - we do not accept W2 only)

* Copy of Social Security cards or identification for all household members

* Copy of all recent bills reported, such as:

• Mortgage/Rent  
• Electric  
• Car Payments  
• Rent-to-Own Centers
• Water  
• Internet
• Health Insurance  
• Storage Building
• Life Insurance  
• PO Box
• Car Insurance  
• Satellite/Cable
• Child Support  
• House Insurance
• Cell Phone  
• Land Line Phone
• Credit Card  
• Student/Personal Loans
• Propane/Natural Gas  
• Medical bills (including monthly medicine)
• Other

* Three recent check stubs for all household members earning income

* Notarized memo from employer verifying income if you do not receive check stubs

* Most recent month's checking and savings statements (if self employed, 6 months worth)

* Verification of Social Security, SSI, VA or any additional income amounts

* Verification of any type of public assistance (e.g. food stamps)

* If you have applied for disability and have not yet been awarded benefits, written verification from the social security office will be required.

* Notarized Statement from individual(s) or organization(s) providing financial support.

Return the application and documentation to our office. We will make copies if needed.
* Appointments ARE necessary; please call to make an appointment.

• If your last name STARTS with A-L call Kay (256) 737-2678.
• If your last name STARTS with M-Z call Flavia (256) 737-2677.

*If mailing documentation, please send copies only. We will not be responsible for original documents.

* Additional documentation may be required depending on individual situations.

* If you have any questions, please contact one of the Couselors above.

Patient Name *  

Account Number *  

Today's Date *  

Application & Supporting Documentation Due Date *  

Guarantor Name *  

Relationship to Patient *  

Social Security Number *  

Date of Birth *  

Sex

Yes
No 

Home Telephone Number *  

Current Address *  

City *  

State *  

Zip Code *  

County of Residence *  

How long have you lived in the residence listed above? *  

Requesting assistance for: * Prior Service Date Future Service Date  

Date of Requested Service *  

Patient's Employer *  

Length of Employment *  

Spouse's Employer *  

Spouse's Length of Employment *  

Do either employer(s) offer health insurance?

Yes
No 

Are you currently unemployed?

Yes
No 

Is your spouse currently unemployed?

Yes
No 

Name of Bank *  

At the bank listed above, do you have a checking account?

Yes
No 

At the bank listed above, do you have a savings account?

Yes
No 

How many people currently live in your household? *  

Do you currently receive child support?

Yes
No 

Do you receive alimony?

Yes
No 

Have you ever applied for SSI/Disability?

Yes
No 

Was this hospital visit accident related?

Yes
No 

Monthly Income and Expense Summary

NOTE: We must receive copies of bills reported below.

Monthly income received (all sources) *  

EXPENSES

Please expenses per month for each item listed below.

Mortgage/Rent $ *  

Satellite/Cable $ *  

Car Payment $ *  

AUTHORIZATION

I authorize Cullman Regional Medical Center (CRMC) or its designated agent to obtain a consumer credit report from a consumer reporting agency that collects consumer credit information and issues reports based upon that information. CRMC will use the report in reviewing my account to determine my ability to pay for medical services. I understand that a consumer report contains information relating to my credit standing, credit capacity, character, general reputation, personal characteristics, and standard of living. I understand that by giving consent to a consumer reporting agency, such as Equifax, may provide CRMC with a consumer report about me, in accordance with the Fair Credit Reporting Act. I certify that all of the information provided is true
and accurate. I agree that if I am eligible for SSI/Medicaid I will complete the forms within 30 days after I receive approval to have Medicaid reimburse CRMC for services provided.

Authorization Approval

I agree
Disagree 

Name for Authorization Approval *