RESURRECTION HEALTH CARE

APPLICATION FOR FINANCIAL ASSISTANCE

Dear Patient,

Thank you for choosing a Resurrection Health Care hospital for your health care needs. We are committed to improving
the health and well being of everyone in our community. We are pleased to offer our financial assistance and charity care
program to help individuals and families who need assistance.

Enclosed is our Financial Assessment form. Please return the completed form with the requested documents by:
___________. If you have questions about the documents or do not have all the documents, please contact the Financial
Counselor at the phone number below. They will gladly assist you. Thank you for your cooperation.

Documents Requested for Determination of Eligibility for Financial Assistance

(Please provide documents from each category as applicable.)

Photo ID / Proof of Identification (one document required)

ƒ Current Driver’s License or State ID
ƒ Current Student or Employee ID Card
ƒ Current Passport
ƒ Current Permanent Resident Card (Green Card)
ƒ Current Matricula Consular

Proof of Income (for each household member, provide all documents that exist and/or apply)
ƒ Pay stubs / proof of tips for past 2 months
ƒ If paid in cash, a signed letter from employer indicating terms of employment, including wages/salary, dates of
employment, current employment status, the availability of any health care benefits, etc.
ƒ If self employed, business records including income, expenses, liabilities and assets for past 2 months
ƒ Copies of checks or award letters from unemployment, Social Security or Veterans Administration
ƒ Copies of checks for child or spousal support
ƒ Proof of other income (for example, interest income, pension, rental income)
ƒ Copy of income tax return from most recent filing period
ƒ Notarized Confirmation of Support Letter

Disclosure of Assets (for each household member, provide all documents that apply)
ƒ Current statement from Checking and Savings Account(s), Certificate(s) of Deposit, Money Market Fund, Trust
Fund or Brokerage Statement

Please submit the requested documents to: Financial Counselor, St. Elizabeth Campus, 1431 N. Claremont, Chicago,
IL 60622-9882. Determinations of Eligibility for Financial Assistance are made within fifteen business days after
receiving all of the requested documents.

Completion of this form is not a guarantee of eligibility for Financial Assistance /Charity Care, or any other
program. Financial Assistance /Charity Care is only considered after all possible sources of coverage or potential
payment (for example, health insurance, Medicare, Medicaid, All Kids, liability insurance) have been exhausted.
Failure to provide all requested documents will result in non-approval.

If you have any questions, please call: ______________________ __________________________

Name Phone Number
Thank you,

Financial Assistance Counselor

Patient Financial Services

Date: ____________________________________ Application #: __________________________

 RESURRECTION HEALTH CARE
FINANCIAL ASSESSMENT FORM

Patient’s Name: ____________________________________________________________________________

Applicant’s
Last Name _______________________________First Name _______________________________M.I. ______Relationship to Patient__________

DETERMINATION OF HOUSEHOLD SIZE

(Please include names and relationship to applicant of all dependents claimed on most recent income tax filing and
household members living in applicant’s home.)

Spouse ______________________________________Rel ______________Household Member____________________________Rel___________

Household Member___________________________Rel _______________Household Member____________________________Rel___________

Household Member___________________________Rel _______________Household Member____________________________Rel___________

DISCLOSURE OF INCOME AND ASSETS

(Please complete each line that applies to you and your household members.)

Applicant’s Income Information (please provide for each employer)

Employer Name: Phone: For Office Use Only

Address: Length of Employment:

Gross Income $:
(Circle One: Wkly, Biwkly, Monthly) $ A

Spouse’s Income Information (please provide for each employer)

Employer Name: Phone:

Address: Length of Employment:

Gross Income $
(Circle One: Wkly, BiWkly, Monthly) $ B

Household Member’s Income Information (please provide for each employer)

Employer Name: Phone:

Address: Length of Employment: $_______________B

Gross Income $

(Circle One: Wkly, BiWkly, Monthly)

Income – Other Sources:

Child Support $ Pension Plan $

Interest Payments: $ Other $ $ C

Bank/Savings & Loan Account Balances

Checking Account $ Savings Account $

Checking Account $ Savings Account $

IRA/Certificates of Deposit $ Trust Fund Account $ $ D

IF ALL YOUR INFORMATION DOES NOT FIT ON THIS SHEET, PLEASE COPY THIS SHEET AND PROVIDE THE INFORMATION
ON THE COPY.
Sender’s Initials and Date Sent
 DOCUMENT CHECKLIST
(Please provide copies of documents from the lists below.)

Photo ID / Proof of Identification (one document required)

• Current Driver’s License or State ID
• Current Student or Employee ID Card, with photograph
• Current Passport
• Current Permanent Resident Card (Green Card)
• Current Matricula Consular

Proof of Income (provide copies of all documents that exist)

• Pay stubs / proof of tips for past 2 months
• If paid in cash, a signed letter from your employer indicating the terms of employment, including wages/salary,
dates of employment, current employment status, the availability of any health care benefits, etc.
• If self employed, business records including income, expenses, liabilities and assets for past 2 months
• Copies of checks or award letters from unemployment, Social Security or Veteran’s Administration
• Copies of checks for child or spousal support
• Proof of other income (for example, interest income, pension, rental income)
• Copy of income tax return from most recent filing period
• Notarized confirmation of support letter

Disclosure of Assets (provide all documents that apply)

• Current statement from Checking and Savings Account(s), Certificate(s) of Deposit, Money Market Fund, Trust
Fund or Brokerage Statement

I understand that qualifying for financial assistance is based on Resurrection Heath Care’s ability to verify the information I have provided. I
hereby certify, by signing below, that the information and documentation provided by me is complete and accurate to the best of my
knowledge.

Applicant’s Signature Date Spouse’s Signature Date

Applicant’s Social Security Number Spouse’s Social Security Number

Address City

State Zip code Home Telephone Number

Application Mailed to Patient Application Hand Delivered to Patient Application Completed Over Phone

Date Logged: ______/______/_______ Logged by: ___________________________________________

 RESURRECTION HEALTH CARE
Confirmation of Support Letter

_______________________________
Applicant (Print)

______________________________________________________
Application Number

The person named above applied for financial assistance to pay their hospital bill and has advised us that you either
contribute substantially to their support or you are their sole means of support. Please complete this form, have it
notarized and return it in the enclosed self-addressed envelope by: ___________________. For assistance finding a
Notary Public, please consult the Illinois Secretary of State’s Office at http://www.ilsos.gov/notary/ or by
calling 1-800 252-8980.

Note: Completing this form does not mean that you will be responsible for the patient’s hospital Bill

Thank you.

The type of support I / we provide is: (please complete all that apply)

______ Room and Board, since (date) ____________________________________

______ Allowance of $ _____________________________________

every week ____, every 2 weeks ____, every month ____

______ Other (please explain) ________________________________________________________

___________________________________________________________________________

I / We, (print) _______________________________________ have been the sole/substantial support for the person
named above and, to the best of my / our knowledge, declare that this person has no other primary means of support.

______________________________ _______________________________
Signature 1 Signature 2 (if jointly providing support)

______________________________ _______________________________
Relationship to Applicant Relationship to Applicant

______________________________ _______________________________
Address, Street City

______________________________ _______________________________
Telephone Date

Subscribed and sworn before me this ______ day of _________________________, A.D.

________________________________________________
Notary Public