Financial Assessment Application


 
 
 
 
 
 
 
 

Sex


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do either employer(s) offer health insurance?


 
 
 
 

Cost of Coverage Provided by Employer

Are you currently unemployed?


 

If you are unemployed, do you receive an unemployment check?


Is your spouse currently unemployed?


 

If your spouse is unemployed, does your spouse receive an unemployment check


 

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


 

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


 
 

Do you currently receive child support?


 

Do you receive alimony?


 

Have you ever applied for SSI/Disability?


 

When you last applied for SSI/Disability, what was the result for your case?



Was this hospital visit accident related?


 

If you answered yes to the question above, was liability insurance involved?


If liability insurance was involved, please provide name/phone number/address/policy information of insurance.

Monthly Income and Expense Summary


NOTE: We must receive copies of bills reported below.
 

EXPENSES


Please expenses per month for each item listed below.
 

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


 
 

PERMISSION TO RELEASE INFORMATION TO THE GOOD SAMARITAN HEALTH CLINIC

If you are uninsured, as resident of Cullman County and between the ages of 19 and 65, you may be eligible for healthcare services through Good Samaritan Health Clinic. Much of the paperwork required to qualify for the hospital's Charity Program is very similar to paperwork needed by the GSC. In an effort to speed up the application process the hospital will, with your permission, provide the GSC with copies of the documentation you have provided us.
I attest that I am a resident of Cullman County and authorize Cullman Regional Medical Center to release financial information I have provided to CRMC as part of my charity application to the Good Samaritan Health Clinic. Any information not to be provided has been designated as such.

Good Samaritan Release Approval