MARYLAND STATE UNIFORM FINANCIAL ASSISTANCE …
[Pages:2]MARYLAND STATE UNIFORM FINANCIAL ASSISTANCE APPLICATION
Information About You
Name: ____________________________________________________________________
First
Middle
Last
Social Security Number ______-____-_____ US Citizen Yes No
Marital Status: Single Married Separated Permanent Resident: Yes No
Home Address ________________________________________________
_________________________________________________
_________________________________________________
City
State
Zip Code
____________________ Country
Employer Name _______________________________________________
Phone _______________
Work Address _______________________________________________
_______________________________________________
City
State
Zip Code
Household Members:
____________________________________ Name ____________________________________ Name ____________________________________ Name ____________________________________ Name ____________________________________ Name ____________________________________ Name ____________________________________ Name ____________________________________ Name
_______ Age
_______ Age
_______ Age
_______ Age
_______ Age
_______ Age
_______ Age
_______ Age
___________________________________ Relationship ___________________________________ Relationship ___________________________________ Relationship ___________________________________ Relationship ___________________________________ Relationship ___________________________________ Relationship ___________________________________ Relationship ___________________________________ Relationship
Have you applied for Medical Assistance ?
Yes No
If yes, what was the date you applied? __________________
If yes, what was the determination ____________________________________________________________
Do you receive any state or County Assistance? Yes No
PRMC ? Patient Accounts 100 East Carroll Street Salisbury, MD 21801
PA-059 (12/05)
I. Family Income
List the amount of your monthly income from all sources. You may be required to supply proof of income, assets, and expenses. If you
have no income, please provide a letter of support from the person providing your housing and meals.
Monthly Amount
Employment
___________________
Retirement/Pension Benefits
___________________
Social Security Benefits
___________________
Public Assistance Benefits
___________________
Disability Benefits
___________________
Unemployment Benefits
___________________
Veterans Benefits
___________________
Alimony
___________________
Rental Property Income
___________________
Strike Benefits
___________________
Military Allotment
___________________
Farm or Self-Employment
___________________
Other Income Source
___________________
Total ___________________
II. Liquid Assets
Current Balance
Checking Account
___________________
Savings Account
___________________
Stocks, Bonds, CD, or Money Market
___________________
Other Accounts
___________________
Total ___________________
III. Other Assets
If you own any of the following items, please list the type and approximate value.
Home
Loan Balance _____________________
Approximate Value___________________
Automobile
Make ______________ Year________
Approximate Value___________________
Additional Vehicle
Make ______________ Year________
Approximate Value___________________
Additional Vehicle
Make ______________ Year________
Approximate Value___________________
Other Property
Approximate Value___________________
Total
___________________
IV. Monthly Expense
Rent or Mortgage Utilities Car Payment(s) Credit Card(s) Car Insurance Health Insurance Other Medical Expenses Other Expenses
Total
Amount
___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________
Do you have any other unpaid medical Bills?
Yes No
For what service? _________________________________________
If you have arranged a payment plan, what is the monthly payment? _______________________________
If you request that the hospital extend additional financial assistance, the hospital may request additional information in order to make supplemental determination. By signing this form, you certify that the information provided is true and agree to notify the hospital of any changes to the information provided within 10 days.
Applicant Signature ____________________________________________ Date ______________________
Relationship to Patient __________________________________________
PA-059 (12/05)
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