FINANCIAL INFORMATION FORM / FINANCIAL ASSISTANCE APPLICATION

338.5502 or 800.526.2121 -- Press 5

: Phone:

City, State, Zip Code:

Account Number(s): Date(s) of Service:

INSTRUCTIONS:
one ith a picture (example: state-issued driver license or Passport with picture, etc.) *
ch a photocopy of the most recent Income Tax return or y
ch a photocopy of one of the following proofs of income: may be used. Contact phone number above for assistance.

Last 2 paycheck stubs r

,

STATUS: Permanent Texas Resident Legal Resident Immigrant Visa Non-Immigrant Visa

MARITAL STATUS (check one): Married Single Divorced

Widowed Other

)
of Dependents (check one)
Full Name Date of Birth
Child Step-Child Guardian Adult/Senior Not Related

EMPLOYMENT SUMMARY
Spouse
Employer Employer

n O n

Employment Status (check one) Employment Status (check one)

e Part Unemployed e Part Unemployed
Housewife Unable to return to work Housewife Unable to return to work

HOUSEHOLD INCOME PER MONT H HOUSEHOLD EXPENSES PER MONTH (Not applicable for FAA)
$ /mo. Housing: Own/Loan Rent
Spouse $ /mo. House Payment $ /mo.
Alimony $ /mo. $ /mo.
Unemployment $ /mo. Car # 1 $ /mo.
Child Support $ /mo. Car # 2 $ /mo.
Survivors Benefit $ /mo. Gasoline $ /mo.
Workers Comp $ /mo. Insurance $ /mo.
Trust Fund $ /mo. TV/ Cable / Phone $ /mo.
Other $ /mo. Food $ /mo.
TOTAL INCOME $ /mo. TOTAL EXPENSES $ /mo.

BANK ACCOUNTS/OTHER (Not applicable for FAA)

Checking Account? (circle one) Yes No Current Balance $
Savings Account? (circle one) Yes No Current Balance $
Yes No Current Value $
If Yes, please describe:

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 FINANCIAL INFORMATION FORM / FINANCIAL ASSITANCE APPLICATION

t under penalty of perjury that the answers I have given are true and correct to the best of my
knowledge.

and/or to determine eligibility for various programs, coverage or assistance.

statements I have made.

incomplete or insufficient to determine your eligibility for financial assistance or if you do not meet the

financial assistance. Memorial Hermann will provide assistance to individuals in applying for such

.
to the fact that I have applied for all possible insurance coverage, including Medicaid, Crime
.

• I understand that if I do not qualify for financial assistance, I will be responsible for the cost
of the care.

Date
Aer compleng this applicaon, please mail, fax or email it and ALL supporng documents to:
Paent Business Services
909 Frostwood Dr., Suite 3:100
Houston, Texas 77024
Aenon: PBS Financial Assistance
Fax: 713-338-4261
E-Mail: [email protected]
Office Use Only
Financial Assistance Approved by Facility CEO / CFO

Approved by:
Name / Signature Title Date

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See reverse side See reverse side

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