Financial Assistance Request Request financial assistance with medical bills Step 1 of 5 – Personal Information 0% Your Name(Required) First Middle Last Your Date of Birth(Required) MM slash DD slash YYYY Your Email Address(Required) Your Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Phone Number(Required)Person Needing Assistance(Required)You can request assistance for any bills for which you are financially responsible. Myself Someone Else Name of Other Person(Required)Please enter the name of the person needing assistance First Middle Last Date of Birth of Person Needing Assistance(Required) MM slash DD slash YYYY Service Date(Required) Past Service Future Service Both Future Service Details(Required)Please describe the nature of the future service(s) needed or scheduled Size of Household(Required)Please include all of the people who are in your household and for whom you are financially responsible. This may include yourself, your spouse, your children or other people you typically claim as a dependent on your taxes.Please enter a number greater than or equal to 1.Household Income(Required)Please include any income earned by any member of your household, not just yourself or the patients whose bills for which you are requesting assistance. Enter each income as the pre-tax dollar amount.Source of IncomePay FrequencyAnnual Income from this Source Employment Full-TimeEmployment Part-TimeSelf-EmployedGiftSocial SecurityOtherHourlyWeeklyBiweelyMonthlyAnnually Add RemoveTotal Annual Household Income(Required)Proof of Income DocumentsPlease add any proof of income documents for yourself and others in your household. A financial counselor will review these documents as part of your request. Drop files here or Select files Accepted file types: bmp, gif, jpg, png, pdf, doc, zip, Max. file size: 15 MB. Household ExpensesOptional. Please include the yearly totals of any recurring expenses in your household.Type of ExpenseFrequency PaidAnnual Total Expense WeeklyBiweelyMonthlyAnnually Add RemoveTotal Annual Household Expenses Consent DocumentsPlease add any consent documents for yourself and others in your household. A financial counselor will review these documents as part of your request. Drop files here or Select files Accepted file types: bmp, gif, jpg, png, pdf, doc, zip, Max. file size: 15 MB. Other DocumentsPlease add any other pertinent documents for yourself and others in your household. A financial counselor will review these documents as part of your request. Drop files here or Select files Accepted file types: bmp, gif, jpg, png, pdf, doc, zip, Max. file size: 15 MB. CommentsPlease add any additional comments or applicable information hereAttestation(Required) By submitting this application I hereby declare that everything that I have stated in this application is correct to the best of my knowledge. Saint Francis Medical Center is authorized to check my credit and employment history. This program will only cover Saint Francis Healthcare System bills. It will not cover any outside doctor services, such as Cape Radiology or Pathology Associates, or any other physician contractors providing services at Saint Francis Medical Center. Those providers will bill their services separately. CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
