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Fap Application Form Sept 2018

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60 views1 page

Fap Application Form Sept 2018

Uploaded by

npt78mf9zy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FINANCIAL STATEMENT PROFILE

Name:____________________________________________ SS#:_____________________________________
Street Address:________________________________________________________________________________
City:___________________ State:____________ Zip:________ Contact Phone#:___________________________
Employer:____________________________________________ Years Employed:__________________________
Are you married? ___ Yes ___ No Spouse’s Name:___________________________________
Number of Dependents (include yourself):__________ Ages:___________________________________________
Number of Household members:_________________________________________________________________

PATIENT’S INCOME INFORMATION SPOUSE/OTHER HOUSEHOLD MEMBER’S INCOME


INFORMATION
Salary: $_____________ Salary: $_____________
Is this amount:___ Hourly ___ Monthly ___Yearly Is this amount:___ Hourly ___ Monthly ___Yearly
Unemployment: $___________________________ Unemployment: $__________________________
Social Security or Disability: $__________________ Social Security or Disability: $_________________
AFDC: $__________ Child Support: $____________ AFDC: $__________Child Support: $___________
Savings Account: $___________________________ Savings Account: $_________________________
Checking Account: $_________________________ Checking Account: $________________________
Other: $___________________________________ Other: $__________________________________

Please check below the services that you received from Emory

___ Emory University Hospital/Emory University Orthopaedics and Spine/ Emory Rehabilitation Hospital/Emory University
Hospital Midtown, Emory University Hospital Smyrna/Emory Saint Joseph’s Hospital of Atlanta/Emory Johns Creek
Hospital

___ The Emory Clinics/Emory Specialty Associates

___ Emory Decatur Hospital/Emory Hillandale Hospital/Emory Long Term Acute Care

PLEASE SUBMIT THE FOLLOWING DOCUMENTS (as applicable) WITH THIS FORM:
___ Last Two Pay Stubs
___ All Bank Statements for the previous two months
___ Last year Tax Return
___ Income Award Letter
___ Proof of Georgia Residency Documents*
*At least one of the following documents: Utility bill(s), driver’s license, or State of Georgia ID card.

THE PRECEDING INFORMATION IS TRUE AND CORRECT:

Signature: _______________________________________________ Date:______________

At any time during the application process, Emory may request additional documentation, such as Medicaid Denial Letter, to
assist the determination of your eligibility for Financial Assistance. Should your financial situation change, Emory may request
a new application. A determination of eligibility for financial assistance will be effective for a maximum of 12 months. A new
application is needed for the re-determination of your eligibility of Financial Assistance after the maximum 12 months approval
period.

Any misrepresentation of the above information may result in the retroactive denial or reduction of financial assistance and the
patient/guarantor being held liable. In addition, Emory Healthcare reserves the right to evaluate a patient’s eligibility under the
Emory Healthcare Financial Assistance Policy from time to time and to adjust the patient’s account as necessary.

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