FA Application – NMC Health

Online Application

"*" indicates required fields

Patient Name*

First Middle Last

Patient Age*

Patient Date of Birth*

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Patient Age

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Patient Date of Birth

Month

Day

Year

Patient Social Security Number*

Patient Address*

Street Address City State ZIP Code

Patient Phone/Cell Number*

Patient Work Phone

Patient's Primary Care Physician

Is the patient a citizen of the United States?*

Yes

Is the patient a legal/permanent resident?*

Yes

Does the patient file a federal tax return or claimed on someone's tax return?*

Yes

Is the patient pregnant?*

Yes

Is the patient employed?*

Yes

Is the patient self-employed?*

Yes

Patient Employment Status*

Full Time

Part Time

Self-Employed

Unemployed

Student

Employer Name

Employer Address

If unemployed, please explain how Patient is being supported financially.

Date of last unemployment check received.

Patient's Marital Status*

Is the patient deceased?*

Yes

Date of death

Is the patient homeless?*

Yes

Homeless Explanation

Is the Patient also the Primary Guarantor for the accounts?

The guarantor is the person responsible for the bills.

Yes

If no, who is the Primary Guarantor?*

First Middle Last

Primary Guarantor Address*

Street Address City State ZIP Code

Primary Guarantor Phone/Cell Number*

Primary Guarantor Date of Birth

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Primary Guarantor Date of Birth

Month

Day

Year

Primary Guarantor Age

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Primary Guarantor Age

Primary Guarantor Social Security Number*

Primary Guarantor's relationship to Patient*

Is the Primary Guarantor pregnant?*

Yes

Is the Primary Guarantor claimed on household taxes?*

Yes

Is the Primary Guarantor employed?*

Yes

Primary Guarantor Employment Status*

Full Time

Part Time

Self-Employed

Unemployed

Student

Employer Name

Employer Address

If unemployed, please explain how Primary Guarantor is being supported financially.

Date of last unemployment check received.

Is there a Secondary Guarantor?*

The guarantor is the person responsible for the bills.

Yes

Name of Secondary Guarantor*

First Middle Last

Is the Secondary Guarantor’s address the same as Patient/Primary Guarantor?*

A secondary guarantor is someone responsible for paying the patient’s medical bills if the primary guarantor is unable or unwilling to do so. This could be another family member or close friend who has agreed to assume financial responsibility for the patient’s medical care.

Yes

Secondary Guarantor Address*

Street Address City State ZIP Code

Secondary Guarantor Phone/Cell Number*

Secondary Guarantor Date of Birth

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Secondary Guarantor Date of Birth

Month

Day

Year

Secondary Guarantor Age

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Secondary Guarantor Age

Secondary Guarantor Social Security Number*

Secondary Guarantor's relationship to patient*

Is the Secondary Guarantor pregnant?*

Yes

Is the Secondary Guarantor claimed on household taxes?*

Yes

Is the Secondary Guarantor employed?*

Yes

Secondary Guarantor Employment Status*

Full Time

Part Time

Self-Employed

Unemployed

Student

Employer Name

Employer Address

If unemployed, please explain how Secondary Guarantor is being supported financially.

Date of last unemployment check received.

Besides those already included on your application, how many other members of your household are there?*

For the purpose of this application, members of the household includes the responsible party, their spouse if applicable, and all dependent children under 18 years old, including unborn children.

Please enter a number from 0 to 7.

Additional Household Member 1 Name*

First Last

Additional Household Member 1 Date of Birth*

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Additional Household Member 1 Date of Birth*

Month

Day

Year

Additional Household Member 1 Age

Additional Household Member 1 relationship to patient*

Additional Household Member 1 Social Security Number*

Is Additional Household Member 1 claimed on household taxes?*

Yes

Is Additional Household Member 1 pregnant?*

Yes

Is Additional Household Member 1 employed?*

Yes

Additional Household Member 2 Name

First Last

Additional Household Member 2 Date of Birth*

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Additional Household Member 2 Date of Birth*

Month

Day

Year

Additional Household Member 2 Age

Additional Household Member 2 relationship to patient*

Additional Household Member 2 Social Security Number*

Is Additional Household Member 2 claimed on household taxes?*

Yes

Is Additional Household Member 2 pregnant?*

Yes

Is Additional Household Member 2 employed?*

Yes

Additional Household Member 3 Name*

First Last

Additional Household Member 3 Date of Birth*

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Additional Household Member 3 Date of Birth*

Month

Day

Year

Additional Household Member 3 Age

Additional Household Member 3 relationship to patient*

Additional Household Member 3 Social Security Number*

Is Additional Household Member 3 claimed on household taxes?*

Yes

Is Additional Household Member 3 pregnant?*

Yes

Is Additional Household Member 3 employed?*

Yes

Additional Household Member 4 Name*

First Last

Additional Household Member 4 Date of Birth

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Additional Household Member 4 Date of Birth*

Month

Day

Year

Additional Household Member 4 Age

Additional Household Member 4 relationship to patient*

Additional Household Member 4 Social Security Number*

Is Additional Household Member 4 claimed on household taxes?*

Yes

Is Additional Household Member 4 pregnant?*

Yes

Is Additional Household Member 4 employed?*

Yes

Additional Household Member 5 Name*

First Last

Additional Household Member 5 Date of Birth

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Additional Household Member 5 Date of Birth*

Month

Day

Year

Additional Household Member 5 Age

Additional Household Member 5 relationship to patient*

Additional Household Member 5 Social Security Number*

Is Additional Household Member 5 claimed on household taxes?*

Yes

Is Additional Household Member 5 pregnant?*

Yes

Is Additional Household Member 5 employed?*

Yes

Additional Household Member 6 Name*

First Last

Additional Household Member 6 Date of Birth

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Additional Household Member 6 Date of Birth*

Month

Day

Year

Additional Household Member 6 Age

Additional Household Member 6 relationship to patient*

Additional Household Member 6 Social Security Number*

Is Additional Household Member 6 claimed on household taxes?*

Yes

Is Additional Household Member 6 pregnant?*

Yes

Is Additional Household Member 6 employed?*

Yes

Additional Household Member 7 Name*

First Last

Additional Household Member 7 Date of Birth

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Additional Household Member 7 Date of Birth*

Month

Day

Year

Additional Household Member 7 Age

Additional Household Member 7 relationship to patient*

Additional Household Member 7 Social Security Number*

Is Additional Household Member 7 claimed on household taxes?*

Yes

Is Additional Household Member 7 pregnant?*

Yes

Is Additional Household Member 7 employed?*

Yes

Insurance Information

Is the patient covered by health insurance or a third-party payer?

Yes

Check all that apply

Medicare

Medicaid

BCBS

Other Insurance

Sharing Group

Other Insurance Company Name

Other Insurance Group Number

Other Insurance Member ID Number

Sharing Group Name

Sharing Group – Group Number

Sharing Group Member ID Number

BCBS Group Number

BCBS Member ID Number

Medicaid Company Name

Medicaid Member ID Number

Medicare Number

Any additional coverage or third-party payers? (Check all that apply)

Lawsuit

Settlement

Personal Injury

Workers’ Compensation

Liability

Crime Victims Compensation

Expected Settlement

Household Income Information
Please provide the total monthly income for all members of your household in each of the following categories. If none, enter 0.

Monthly Gross Wages Before Taxes*

Monthly Workers' Comp Income*

Monthly Short/Long Term Disability Income*

Monthly Unemployment Income*

Monthly Rental Income*

Monthly Interest/Dividends Income*

Monthly Pension/Retirement Income*

Monthly Veteran's Benefits Income*

Monthly SSI/SSDI Social Security Income*

Monthly Alimony/Child Support Income*

Case #

County

Other Monthly Income*

Is someone outside of your household financially supporting you?

Yes

Please have the person who is providing financial support complete this section.

Name of Supporter

First Last

Name of Patient You are Financially Supporting

First Last

Date You Started Supporting Patient

Relationship to Patient

Telephone Number

Additional Comments (if any)

Signature

Household Banking and Current Asset Information
Please provide the total household monthly balance in each of the following categories. If none, enter 0.

Checking Account(s)*

This is the total balance of ALL checking account(s) owned by members of the household.

Savings Account(s)*

This is the total balance of ALL savings account(s) owned by members of the household.

IRA/CD(s)*

This is the total balance of ALL IRAs/CDs owned by members of the household.

Stocks/Bonds*

This is the total balance of ALL stocks/bonds owned by members of the household.

Government Cash Assistance*

This is the total balance of ALL government cash assistance granted to members of the household.

Livestock (market value)*

This is the total market value of ALL livestock owned by members of the household.

Property/Land (market value)*

This is the total market value of ALL property/land owned by members of the household.

Rental Property (market value)*

This is the total market value of ALL rental property owned by members of the household.

Other Asset(s)*

Personal Property (Please select all that apply)

Auto

Motorcycle

Boat

Jet Ski

Travel Trailer

Other

Specify Other Personal Property

Total Estimated Value of Personal Property

Is there any additional information or explanation you would like to provide regarding your assets?

Personal Statement

Please write detailed information in the space provided below describing your current financial situation and why you are unable to pay your balance or make monthly payments. Please be specific.

Statement

In order to process your application, we need supporting documents to verify your financial situation.

Required documents include any of the following that apply to your household:

Required Docs

Last Year’s Tax Return & W-2’s

Bank Statements both Checking and Savings (3 months prior to date of service)

Paycheck Stubs (3 months prior to date of service)

Social Security/Disability Benefit Letter(s)

Pension Verification Letter

Government Cash Assistance Benefits Letter

Alimony/Child Support Statement

Unemployment Statement

U.S. Permanent Resident Card

You may submit pictures or electronic files through this online application. If you do not have your documents ready at this time, please answer “no” to the question below.

Do you have your proof of income documents ready?*

Yes

Please mail in, drop off, or upload your proof of income documents in the next 10 days. The address to send or drop off your documents to is: NMC Health, 600 Medical Center Drive, Newton, KS 67114. You may also return to this site later and select the “Submit Supporting Documents” button on the home page.

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.

Tax Returns & W-2's

Please upload last year’s complete income tax return & W-2 forms, if applicable.

Drop files here or

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

Bank Statements

Please upload bank statements from all checking and savings accounts from 3 months prior to the date of service, if applicable.

Drop files here or

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

Pay Stubs

Please upload the pay stubs from 3 months prior to date of service for all income earners, if applicable.

Drop files here or

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

Social Security/Disability Benefits Letter

Please upload most recent Social Security/Disability benefit letters, if applicable.

Drop files here or

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

Pension Verification Letter

Please upload most recent pension verification letters, if applicable.

Drop files here or

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

Government Cash Assistance Benefits Letter

Please upload most recent government cash assistance benefits letters, if applicable.

Drop files here or

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

Alimony/Child Support Records

Please upload most recent alimony/child support records, if applicable.

Drop files here or

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

Unemployment Statement

Please upload most recent unemployment statements, if applicable.

Drop files here or

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

U.S. Permanent Resident Card

Please upload a copy of your U.S. permanent resident card, if applicable.

Drop files here or

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

Death Certificate

Please upload a copy of the patient’s death certificate, if applicable.

Drop files here or

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

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Test – Patient Age

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Number

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Family Additionals

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Total Family Size

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Family Additional Total 5380

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Yearly Rate 15060

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Total 12 Month Income Div by 12

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Calculated % FPL 12 Months

Certification and Signature

I wish to apply for financial assistance through NMC Health. I understand that NMC Health expects patients to use all of their available financial resources to pay their medical bills before financial assistance will be granted. I also understand that submission of my application does not guarantee approval for healthcare assistance. I certify that the information I have provided above is true and complete. By signing this form, I agree to allow NMC Health to check employment and credit history for the purpose of determining my eligibility for financial assistance. I also agree to allow organizations and facilities to release information concerning my financial status to NMC Health for the purpose of determining my eligibility for financial assistance. I understand that I may be required to provide proof of the above information. I understand NMC Health reserves the right to reverse any charity approval if substantial information was not disclosed, or information was misrepresented or deliberately withheld. In such cases, charity approvals will be reversed and NMC Health will pursue full patient responsibility. If my application is incomplete or information is found to be false or misleading, I understand my application will be denied. NMC Health reserves the right to request additional income documentation if there is a discrepancy between stated household income and documented household income.

Applicant’s Signature*

Any application without signatures and/or the necessary documentation will not be processed until information is received.

Co-Applicant’s Signature

Are You Ready to Submit Your Application?*

I’m Ready

You can press the previous button below to go back to prior pages and complete your application. Please note, if you do not submit your application your information will not be saved for security purposes.

On a scale from 1-5, with 1 being HARD and 5 being EASY, how was your experience applying for Financial Assistance online?
Please enter a number from 1 to 5.

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