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