Compassionate Care Application Compassionate Care Application Please find attached the following documents that will be required to be completed by you and returned to our Patient Financial Counselor within the next 15 days. If you are unable to do so or need assistance then please contact the Patient Financial Counselor at 574-224-1446. Each document requires your financial history as well as supporting documentation. If you would like to be considered for this program, please take the following steps and check off each step as it is completed. • You must apply for Medical Assistance (Medicaid) and furnish evidence of denial. • If you are unemployed and receiving unemployment benefits then please provide us with a copy of your unemployment letter or acceptance. • Attach a complete copy of your Federal Tax Return and W2’s. • Attach a copy of 2 current complete bank statements on all bank accounts. • Attach copies of 2 current pay stubs on all who work in household. • If you’re receiving Food Stamps then please provide a letter of approval for Food Stamps with the dollar amount from the Department of Family and Children. • If you’re receiving Child Support please provide a letter of proof and the dollar amount received. • If you are living with someone and you’re not working, we will need a letter from whoever is helping you with your financial needs. • Complete all sections, sign and date the application. Failure to return all documents will delay the process of your application. Remember, if you have any questions or concerns or require assistance in completing your Compassionate Care forms then please contact: Patient Financial Counselor at 574-224-1446 Between the hours of 8:00am and 4:00pm 1400 East 9th Rochester, Indiana 46975 Telephone: 574-224-1446 Facsimile: 574-406-9116 www.woodlawnhealth.org Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Patient Phone(Required)Email(Required) Enter Email Confirm Email SSN:(Required)Date of Birth(Required)Please place birthday of patient MM slash DD slash YYYY Marital StatusMarriedDivorcedSingleWidowedLegally SeparatedSpouses Name First Last DependentsNameAgeRelationship Add RemoveEmployment HistoryEmployerEmployers Phone NumberSpouses Employment Status Full Time Part Time Spouses EmployerSpouse Employers Phone NumberSpouses Employment Status Full Time Part Time Income DetailsIncome SourceIncomeSpouses IncomeSocial SecuritySpouse Social SecurityUnemploymentSpouse UnemploymentVeterans AdminSpouse Veterans AdminWorkman CompSpouse Workman CompChild SupportSpouse Child SupportAlimonySpouse AlimonyMonthly Income Income SourceIncomeSpouses IncomeSocial SecuritySpouse Social SecurityUnemploymentSpouse UnemploymentVeterans AdminSpouse Veterans AdminWorkman CompSpouse Workman CompChild SupportSpouse Child SupportAlimonySpouse AlimonyMonthly Income Income SourceIncomeSpouses IncomeSocial SecuritySpouse Social SecurityUnemploymentSpouse UnemploymentVeterans AdminSpouse Veterans AdminWorkman CompSpouse Workman CompChild SupportSpouse Child SupportAlimonySpouse AlimonyMonthly Income Income SourceIncomeSpouses IncomeSocial SecuritySpouse Social SecurityUnemploymentSpouse UnemploymentVeterans AdminSpouse Veterans AdminWorkman CompSpouse Workman CompChild SupportSpouse Child SupportAlimonySpouse AlimonyMonthly Income Assets and SavingsCheckingSavingsRental PropertyCD'sIRA'sPensionOtherMonthly Total Including Spouse Assets and SavingsCheckingSavingsRental PropertyCD'sIRA'sPensionOtherMonthly Total Including Spouse Assets and SavingsCheckingSavingsRental PropertyCD'sIRA'sPensionOtherMonthly Total Including Spouse Monthly Total Including Spouse Monthly Total Including Spouse Assets and SavingsCheckingSavingsRental PropertyCD'sIRA'sPensionOtherMonthly Total Including Spouse Assets and SavingsCheckingSavingsRental PropertyCD'sIRA'sPensionOtherMonthly Total Including Spouse Assets and SavingsCheckingSavingsRental PropertyCD'sIRA'sPensionOtherMonthly Total Including Spouse Assets and SavingsCheckingSavingsRental PropertyCD'sIRA'sPensionOtherMonthly Total Including Spouse Liabilities: (Debts and Bills)BillsSelect All that ApplyMortgage/RentCredit UnionBanksCredit CardAuto LoansStudent LoansOtherMonthly Cost(Required) BillsSelect All that ApplyMortgage/RentCredit UnionBanksCredit CardAuto LoansStudent LoansOtherMonthly Cost 2(Required) BillsSelect All that ApplyMortgage/RentCredit UnionBanksCredit CardAuto LoansStudent LoansOtherMonthly Cost 4 BillsSelect All that ApplyMortgage/RentCredit UnionBanksCredit CardAuto LoansStudent LoansOtherMonthly Cost 3 AssetsPropertyHomestead LocationAssessed Taxable ValueMortgage DueOther Property LocationAssessed Taxable ValueMortgage DueAssets/AutoMake and YearEst ValueLoan BalanceMake and YearEst ValueLoan BalanceBoat with MotorEst ValueLoan BalanceMotorcycleEst ValueLoan BalanceThree Wheller/QuadEst ValueLoan BalanceMotor HomeEst ValueLoan BalanceSnowmobileEst ValueLoan BalanceRegular Monthly ExpensesRentMortgage PaymentUtilitiesAuto LoanOther Loan PaymentInsurance PremiumsContinuous MedicationOther, please stateAmountOther, please stateAmountIf you have not listed any income or earnings for the family, please explain how the family is supported. For example, how do you pay for your rent, for your groceries, etc?Do you now have a claim pending or plan to file a claim with an attorney for unemployment compensation, worker’s compensation, or a third party liability? Yes No Consent(Required)Omitting information or providing fraudulent information will be a cause for permanent denial. PLEASE NOTE: Processing may be delayed if necessary verification is not provided. I hereby certify that all information is true to the best of my knowledge and give Woodlawn Hospital permission to verify the above information and check my credit through the credit bureau. I consent to all aboveToday's Date MM slash DD slash YYYY
