Financial Assistance Application English
Financial Assistance Application
Patient/Guarantor Information
Patient's Name: __________________________________________________________________________
Guarantor's Name (if patient is under 18 years of age): __________________________________________
Patient's Address: ________________________________________________________________________
City: ______________ State/ZIP: _______________________ Patient's Date of Birth: _______________
Patient's Medical Record Number: __________________
Current Marital Status: Single
Married Separated Divorced Widowed
Spouse Information Spouse's Name: __________________________________________________________________________ Spouse's Address (if different from patient): __________________________________________________ City: _______________ State/ZIP: ______________________ Spouse's Date of Birth: _________________ Spouse's Medical Record Number: __________________
Note: If you are married, then spouse's financial information and signature is required in order for application to be processed.
Household Information Household Size/Dependents (including yourself & spouse): ______________________________________ Please provide dependents name, Date of Birth, and Medical Record Number (if applicable)
Household Income (Gross): ________________________________________________________________ Income is defined as wages, profits from business, rental income from rental properties, social security income [SSI/SSDI], income from investments, retirement/pension, alimony, etc.
Employment Information
Patient/Guarantor Employed Self-Employed Unemployed Full time student Dependent on Others Retired
Spouse Employed Self-Employed Unemployed Full time student Dependent on Others Retired
Please send proof of monthly household income by providing one of the documents listed below. If you claim dependents you must provide a tax return.
(Pay Stubs, SSI/Disability, W2/Retirement/Pension, Tax Returns, Letter from Employer).
If no income, please provide explanation of how you pay daily living expense: _________________________________________________________________________________________________ _________________________________________________________________________________________________
Please Check Box if you authorize us to update your demographic information (Address, Marital Status, etc.)
Patient/Guarantor's Signature: _______________________________________ Date: __________________ Spouse's Signature: ________________________________________________ Date: __________________
Send Completed Financial Assistance Application to:
Fax: 919-620-1241 Email: PRMOSelfPayReimb@dm.duke.edu Mail: PRMO Self-Pay
PO Box 110566 Durham, NC 27709
Contact Information: 919-620-4555 or 800-782-6945
Please allow 4-6 weeks for processing
Additional Comments
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