Arlington Memorial Hospital 500 E Border Street #130
Harris Methodist Hospitals Arlington Texas 76010
682-236-3000 / 800-890-6034
Presbyterian Hospitals
[email protected]Date: ________________________
APRIL 16TH, 2020 Guarantor Name: _________________________
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Patient Name: _______________________________
JAXON SCOTT Date of Service: _____________
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Hospital Account #____________________________ Text
Medical Record # _____________
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Dear Patient:
Attached you will find the Texas Health Resources Financial Assistance Application. Completion of
this application will enable us to present your account for consideration of financial assistance for
your hospital bill(s). This is for your hospital charges only.
We understand your desire for privacy. Accordingly, except for verification purposes, the
information included in your application will be treated as confidential information. It will only be
shared within Texas Health Resources on a need to know basis.
Please complete each item on the application. If you need additional space for any explanations,
please utilize the back of the application.
Please provide copies of your current month and two prior months pay stubs and/or proof of any
other form of income for the household. If you do not receive check stubs, please provide copies
of your bank statements showing your monthly deposits. If self-employed, please provide a copy
of your most recently filed personal income tax return and a current profit and loss statement.
Failure to provide the requested documentation can result in a denial for financial assistance
consideration.
It is extremely important that you complete this application upon receipt and return it as soon as
possible.
If you have difficulty completing this application or there is an area that is unclear, please call. Your
cooperation is appreciated.
Revised 5/2/18
Arlington Memorial Hospital 500 E Border Street #130
Harris Methodist Hospitals Arlington Texas 76010
682-236-3000 / 800-890-6034
Presbyterian Hospitals [email protected]
APPLICATION FOR FINANCIAL ASSISTANCE – Page 1
Patient Name: Last First MI
Social Security # DOB: Hospital Account #:
Married Single Divorced Widowed Separated
Do you have minor children (under 18)? Yes No
Do they live with you? Yes No
Are they your birth/legally adopted children? Yes No
Patient Employed? Yes No
Spouse Employed? Yes No
Do you have medical insurance? Yes No
Are you on disability? How long? Yes No
Are you a veteran? Yes No
FAMILY MEMBERS – (Living in the home)
Spouse:
Child: Age:
Child: Age:
Child: Age:
Child: Age:
INCOME (Monthly Amount):
Gross Net Expenses Monthly Amount
Patient $ $ Mortgage/Rent $
Spouse $ $ Utilities $
Dependants $ $ Car Payments $
Public Assistance $ $ Food / Groceries $
Food Stamps $ $ Credit Cards $
Social Security $ $ Other (please specify)
Unemployment $ $ $
Strike Benefits $ $
Worker’s
TOTAL
Compensation $ $ $
Alimony $ $
Child Support $ $
Military Allotments $ $
Pensions $ $
Income from: CD’s
Rent, Dividends
Interest $ $
TOTAL $ $
ASSETS
Checking Account $
Savings Account $
CD’s, IRA’s $
Other Investments (Stocks, bonds, etc.)
Properties/Land other than primary residence
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$
$
Revised 5/2/18
Arlington Memorial Hospital 500 E Border Street #130
Harris Methodist Hospitals Arlington Texas 76010
682-236-3000 / 800-890-6034
Presbyterian Hospitals [email protected]
APPLICATION FOR FINANCIAL ASSISTANCE – Page 2
Name of Employer Spouse’s Employer:
Telephone # Telephone #
Employer Address Employer Address
Occupation Occupation
Are you currently applying for Medicaid Benefits? Yes No
Have you applied for assistance thru your county hospital/indigent program? Yes No
Is your physician donating his/her services? Yes No
Are there any potentially liable third-parties responsible for your accident/injury/
Yes No
illness?
Is anyone assisting you with payment of your hospital bills? Yes No
Who is assisting you?
How much assistance are you receiving?
List any other information you feel would be helpful to us in determining your eligibility for assistance in
paying your hospital bill.
Expected earnings and/or funds you will receive during your time off due to your illness
(Sick leave, paid time off, short/long term disability income). $_______________
Expected length of time you will be unable to work and/or earn wages: ________________
I understand that Texas Health Resources may verify the financial information contained in this application in connection
with the hospital’s evaluation of this application, and hereby authorize the hospital to contact my employer to certify the
information provided and to request reports from credit reporting agencies. I am aware that this information will be used
to determine my eligibility for financial assistance and that the falsification of information in this application may result in
denial of Financial Assistance care assistance. I also understand that any Financial Assistance approval may be
completely or partially reversed in the event of a recovery from a third-party or other source.
I further understand that any Financial Assistance care I receive shall not be construed as a waiver by hospital of its
hospital lien for reimbursement of any amount I owe and that any reimbursement I receive relating to this hospitalization
must be sent to Texas Health Resources.
Signature of Person Making Request, If Patient Date
Signature of Person Making Request, If Not Patient Relationship
Patient’s Address City State ZIP County Home Telephone Number
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Revised 5/2/18
