Personal Information Name (First & Last) * Address * Phone Number * Email *
Source of Income- Self Employer: Address Phone Job Title: Salary: Hours/Weekly: Source of Income- Spouse Employer: Address Phone Job Title: Salary: Hours/Weekly: Other (child support, alimony, Federal assistance, social security, etc.) Dependents- please include relationship: What Do You Need Help With? Please choose one Help with current bills I don't have insurance and need to see a provider Documentation
Please attach the documents either in JPG or PDF form for each section. If a payment plan is needed, you will need to upload the Payment Plan Form that is linked on the previous page.
Current Income Tax Return (form 1040,1040A, 1040EZ, Schedules C, E, and F is applicable) Max. file size: 50 MB. Payroll check stubs for the past 30 days Max. file size: 50 MB. Current Medicaid denial – Visit a Human Arc representative located in the hospital’s Patient Access Department. Max. file size: 50 MB. Copies of social security, disability income, unemployment, alimony, child support, dividends, interest, rental income, or any other income. Max. file size: 50 MB. Proof of primary residence (state issued ID or other requested documentation in the absence of an ID, for example lease agreement, utility bill, etc.) Max. file size: 50 MB. Payment Plan Form (linked on the previous page) Max. file size: 50 MB. Signature Signature *
Before you sign, did you include all supporting documents required on previous page? Incomplete applications will not
be processed until all documentation is submitted.
I acknowledge that I have received and understand the provisions included in the Financial Assistance Policy. I
also understand that all information submitted will be kept in strict confidence. I attest that the above
information is true and correct status.
MM slash DD slash YYYY
We may use your contact information to tell you about health-related benefits or services that may be of interest to you.