Connecticut Children S Financial Assistance Application

CONNECTICUT CHILDREN’S FINANCIAL ASSISTANCE APPLICATION

PATIENT NAME:

PATIENT #:

MEDICAL RECORD #:

I. RESPONSIBLE PARTY

LAST NAME FIRST NAME MI MARITAL STATUS SOCIAL SECURITY #

STREET ADDRESS

HOW LONG AT THIS CITY STATE ZIP ADDRESS? HOME PHONE

EMPLOYER'S NAME AND ADDRESS BUSINESS PHONE LENGTH OF EMPLOYMENT

POSITION/TITLE MONTHLY INCOME PAY PERIOD $

II. SPOUSE’S INCOME

LAST NAME FIRST NAME MI MARITAL STATUS SOCIAL SECURITY #

STREET ADDRESS

CITY STATE ZIP HOW LONG AT THIS ADDRESS? HOME PHONE

EMPLOYER'S NAME AND ADDRESS BUSINESS PHONE LENGTH OF EMPLOYMENT

POSITION/TITLE MONTHLY INCOME PAY PERIOD $

III. HOUSEHOLD INFORMATION (ALL PERSONS IN HOUSEHOLD)

NAME DOB RELATIONSHIP

TOTAL PERSONS IN HOUSEHOLD:

1 IV. MISCELLANEOUS INCOME PER MONTH

DIVIDENDS, INTEREST $ PENSIONS $ PUBLIC ASSISTANCE/FOO INVESTMENT/REN D STAMPS $ TAL INCOME $ SOCIAL SECURITY $ GRANTS $ UNEMPLOYMENT/ WORKER’S COMPENSATION $ Other $ CHILD SUPPORT/ALIMON Y $ TOTAL MONTHLY MISCELLANEOUS INCOME: $

VI. MONTHLY INCOME

RESPONSIBLE PARTY's MONTHLY INCOME $ SPOUSE's MONTHLY INCOME (If Applicable) + $0 TOTAL MONTHLY MISCELLANEOUS INCOME + $ TOTAL MONTHLY MISCELLANEOUS EXPENSES - $ TOTAL MONTHLY NET INCOME = $

INCOMPLETE OR FRAUDULENT APPLICATIONS WILL BE DENIED

IN COMPLETING THIS FINANCIAL STATEMENT, I HEREBY AFFIRM THAT THE ABOVE STATEMENTS ARE CORRECT AND COMPLETE, AND I GIVE MY CONSENT TO FURTHER VERIFICATION BY {HOSPITAL NAME} OR ITS AGENTS.

SIGNATURE/ DATE: ______/______

RELATIONSHIP IF OTHER THAN PATIENT: ______

VERBAL CONSENT: ______

APPROVED 45%_____ 100%_____

DENIED ______

Please be advised that you may be asked to provide verification of income (tax return or pay stubs) upon review of your application. You will be contacted by a financial counselor via phone if this information is required. Otherwise, you will receive a determination phone call and letter in the mail indicating the outcome of the application.