Uncompensated Care Application Form

Reference #:

Date:

Head of Household or Guarantor Information

Patient Name:
First Last

Social Security# (secure):

Patient DOB:

Marital status:

Medical Record #:

Mailing Address:

P.O. Box / Suite#:

City:

State:

Zip Code:

County:

Phone:

Email:

Are you applying for an Uncompensated Care discount?

Yes No

Citizenship

Is everyone applying a US citizen or US National? Yes No (If no complete section below)

Last name

First name

Immigration status

Date entered the US

Last name

First name

Immigration status

Date entered the US

Last name

First name

Immigration status

Date entered the US

Last name

First name

Immigration status

Date entered the US

Employment/Work History - Head of Household

Please include all employment information for the past 30 days.

Employer 1

Name:

Address:

Telephone:

Start date:

End date:

$ hourly rate:

hours/week:

How often paid?

Do you receive tips:

Yes No

if yes amount/month:

Employer 2

Name:

Address:

Telephone:

Start date:

End date:

$ hourly rate:

hours/week:

How often paid?

Do you receive tips:

Yes No

if yes amount/month:

Employer 3

Name:

Address:

Telephone:

Start date:

End date:

$ hourly rate:

hours/week:

How often paid?

Do you receive tips:

Yes No

if yes amount/month:

Employer 4

Name:

Address:

Telephone:

Start date:

End date:

$ hourly rate:

hours/week:

How often paid?

Do you receive tips:

Yes No

if yes amount/month:

Other Income
Please submit supporting documentation with your completed application.

Income Type	Monthly Amount
Child Support:
Self-Employment Income - Self:
Self-Employment Income - Spouse:
Other Income:
Unemployment:
Alimony:
Social Security:

No Income

If no income has been reported, explain how you pay for your living expenses such as food, housing, clothing, and other things you need:

Liquid Assets

(Stocks, Bonds, Checking, Savings, Money Market, Certificate of Deposit accounts) Liquid asset information is not collected for outpatient discounts

Name of Financial Institution

Account Type

Owner(s) Name

Current Balance

Name of Financial Institution

Account Type

Owner(s) Name

Current Balance

Name of Financial Institution

Account Type

Owner(s) Name

Current Balance

Name of Financial Institution

Account Type

Owner(s) Name

Current Balance

Name of Financial Institution

Account Type

Owner(s) Name

Current Balance

Certification

I, the undersigned, certify that the completed information in this document is true and accurate to the best of my knowledge.

I will apply for any and all assistance that may be available to help pay this bill.

I understand the information submitted is subject to verification; therefore, I grant permission and authorize any bank, insurance co., financial institution and credit grantors of any kind to disclose to any authorized agent of Hennepin Healthcare information as to my past and present accounts, policies, experiences and all pertinent information related thereto.

I understand that I might be asked to provide documentation to verify my information.

If the application is incomplete, it will be returned. We will not be responsible for follow-up on incomplete applications.

If you do not qualify for Uncompensated Care or have any copays or deposit balances remaining after 90 days from the service date, your balance may be placed with a collection agency. If your balance is not paid to the collection agency, Hennepin Healthcare is authorized to place your balance with the Department of Revenue. During this time any state taxes, property taxes, or lottery winnings will be forwarded to Hennepin Heatlhcare to satisfy your outstanding balance.

As Patient/Guarantor, , I certify that checking this box the equivalent of my signature.

I Agree

Date:

As Patient/Guarantor Spouse, , I certify that checking this box the equivalent of my signature.

I Agree

Date: