FA Application – CHI Mercy Medical Center

Online Application

"*" indicates required fields

Welcome to your CommonSpirit Health online financial assistance application!

In order to process your application, we need supporting documents to verify your financial situation. Required proof of income documents include any of the following that apply to your household, for example:
Last year’s income tax return, including schedules if applicable; or
A “W-2” withholding statement; or
Current pay stubs (3 months); or
Written, signed statements from employers or others

After reviewing your submitted application, we may reach out to assist you with additional programs and insurance options available to you.

Please get an electronic copy or pictures of your documents ready before starting your application. If you submit an incomplete application, we will reach out to you for any additional information or documentation needed to process your application.

Patient and Applicant Information

Patient Name*

First Middle Last

Patient Date of Birth*

Patient Social Security Number (Optional)

Patient Account Numbers

Address

Street Address City State ZIP / Postal Code

Main Contact Number*

If 18 years old or older, Patient’s Employer(s) Name or Source of Income

If 18 years old or older, Patient’s Total Gross Monthly Income (Before Taxes)

Is the Patient the person responsible for paying for care?

Yes

Person Responsible for Paying Bill*

First Last

Relationship to Patient

Responsible Party Date of Birth*

Responsible Party Social Security Number (Optional)

Employment status of person responsible for paying bill. (Please check all that apply)

Employed

Unemployed

Self-Employed

Student

Disabled

Retired

Other

Date of hire

How long unemployed

Other please identify

Responsible Party – Employer(s) Name or Source of Income (If Applicable)

Responsible Party – Total gross monthly income (before taxes)

Family Information

Including yourself, what is the total number of people living in your household?*

“Family” includes two or more people related by birth, marriage, or adoption who live together. If a patient can claim someone as a dependent on his or her income tax return, that person would be a member of the Patient’s family for purposes of this Application.

Please enter a number from 1 to 9.

Additional Family Member 1 – Name

First Last

Additional Family Member 1 – Name

First Last

Additional Family Member 1 – Date of Birth

Additional Family Member 1 – Relationship to Patient

Additional Family Member 1 – If 18 years old or older, Employer(s) Name or Source of Income

All adult family members’ income must be disclosed. Sources of income include, for example: wages, unemployment, self-employment, worker’s compensation, disability, SSI, child/spousal support, work study programs (students), pension, retirement account distributions, and other.

Additional Family Member 1 – If 18 years old or older, Employer(s) Name or Source of Income

Additional Family Member 1 – If 18 years old or older, Total Gross Monthly Income (Before Taxes)

Additional Family Member 1 – Also applying for financial assistance?

Yes

Additional Family Member 1 – Also applying for financial assistance?

Yes

Additional Family Member 2 – Name

First Last

Additional Family Member 2 – Name

First Last

Additional Family Member 2 – Date of Birth

Additional Family Member 2 – Relationship to Patient

Additional Family Member 2 – If 18 years old or older, Employer(s) Name or Source of Income

Additional Family Member 2 – If 18 years old or older, Total Gross Monthly Income (Before Taxes)

Additional Family Member 2 – Also applying for financial assistance?

Yes

Additional Family Member 2 – Also applying for financial assistance?

Yes

Additional Family Member 3 – Name

First Last

Additional Family Member 3 – Name

First Last

Additional Family Member 3 – Date of Birth

Additional Family Member 3 – Relationship to Patient

Additional Family Member 3 – If 18 years old or older, Employer(s) Name or Source of Income

Additional Family Member 3 – If 18 years old or older, Total Gross Monthly Income (Before Taxes)

Additional Family Member 3 – Also applying for financial assistance?

Yes

Additional Family Member 3 – Also applying for financial assistance?

Yes

Additional Family Member 4 – Name

First Last

Additional Family Member 4 – Name

First Last

Additional Family Member 4 – Date of Birth

Additional Family Member 4 – Relationship to Patient

Additional Family Member 4 – If 18 years old or older, Employer(s) Name or Source of Income

Additional Family Member 4 – If 18 years old or older, Total Gross Monthly Income (Before Taxes)

Additional Family Member 4 – Also applying for financial assistance?

Yes

Additional Family Member 4 – Also applying for financial assistance?

Yes

Additional Family Member 5 – Name

First Last

Additional Family Member 5 – Name

First Last

Additional Family Member 5 – Date of Birth

Additional Family Member 5 – Relationship to Patient

Additional Family Member 5 – If 18 years old or older, Employer(s) Name or Source of Income

Additional Family Member 5 – If 18 years old or older, Total Gross Monthly Income (Before Taxes)

Additional Family Member 5 – Also applying for financial assistance?

Yes

Additional Family Member 5 – Also applying for financial assistance?

Yes

Additional Family Member 6 – Name

First Last

Additional Family Member 6 – Name

First Last

Additional Family Member 6 – Date of Birth

Additional Family Member 6 – Relationship to Patient

Additional Family Member 6 – If 18 years old or older, Employer(s) Name or Source of Income

Additional Family Member 6 – If 18 years old or older, Total Gross Monthly Income (Before Taxes)

Additional Family Member 6 – Also applying for financial assistance?

Yes

Additional Family Member 6 – Also applying for financial assistance?

Yes

Additional Family Member 7 – Name

First Last

Additional Family Member 7 – Name

First Last

Additional Family Member 7 – Date of Birth

Additional Family Member 7 – Relationship to Patient

Additional Family Member 7 – If 18 years old or older, Employer(s) Name or Source of Income

Additional Family Member 7 – If 18 years old or older, Total Gross Monthly Income (Before Taxes)

Additional Family Member 7 – Also applying for financial assistance?

Yes

Additional Family Member 7 – Also applying for financial assistance?

Yes

Insurance Information and Screening Information

At your service date did the patient have any plan, group or insurance that reimburses medical expenses?*

Yes

Insurance Company Name

Insurance Member ID

Insurance Group Number

Subscriber Name

Subscriber Date of Birth

Does the patient receive state public services such as food stamps or WIC (Women, Infants, and Children)?*

Yes

Has the patient applied for Medicaid?*

Yes

Are these services a result of a motor vehicle accident or work injury?*

Yes

Is the patient currently homeless?

Yes

Do you need an interpreter?

Yes

If yes, list preferred language

List of CommonSpirit Health hospital(s) where patient was treated.

Uploading Documents

This section is for attaching the documents we need to fully process your application and verify the information you provided. Please include copies of all of the following that apply to your household.

Proof of income documentation for all family members 18 years old or older

Examples of proof of income include: last year’s income tax return, including schedules if applicable, or a “W-2” withholding statement, or current pay stubs (3 months), or written, signed statements from employers or others. You may also upload an approval/denial of eligibility for Medicaid and/or state-funded medical assistance, or approval/denial of eligibility for unemployment compensation.

Drop files here or

Max. file size: 50 MB, Max. files: 10.

Proof of asset documentation for all family members 18 years old or older (optional)

This section is optional and may be used to determine eligibility for other assistance programs. Please provide proof for every identified asset source. Examples of proof of assets include: current bank statements for checking and savings account(s) showing most recent 3 months, investments, including stocks and bonds, trust funds, money market account(s), mutual funds, other investment funds that will not incur a penalty if funds are withdrawn.

Drop files here or

Max. file size: 50 MB, Max. files: 10.

Insurance card front/back

Please attach pictures or copies of the front and back of your medical insurance or Medicaid card effective at the time of service, if applicable.

Drop files here or

Max. file size: 50 MB, Max. files: 10.

Additional Information

Is there any other information about your current financial situation that you would like us to know, such as financial hardship, excessive medical expenses, seasonal or temporary income, or personal loss?

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