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Spencer Hospital Patient Payment Assistance Application

Depending on your current income level, you may qualify for additional payment assistance. A Spencer Hospital financial counselor can assist you with your application.

Before applying, please review the Financial Assistance Information Sheet.

To apply, please fill out the application below.

All fields marked with * are required.

Applicant Information
Spouse Information (if applicable)
Household Members

Please include all household members, including dependent children under 18 years old living in your household.






Income

Monthly Household Income

Applicant Income Information

Spouse Income Information

Monthly Household Expenses
Assets (Current Market Value)




Liabilities
Bank Information

Application Submission

To submit this application, please include the following:

  1. Completed, signed and dated application by Guarantor and Spouse
  2. Proof of Income
    1. Most recent year Federal and State tax returns with ALL required schedules and W-2
    2. Last 3 months paystubs for guarantor and spouse
    3. Other income documentation, such as but not limited to:
  3. Bank statements from the past 2-3 months

Your application will not be considered without the above documentation and may be returned to you along with a letter detailing the documentation missing.


CONSENT FOR RELEASE OF INFORMATION

I hereby verify that the information given to Spencer Hospital is true and correct. I authorize Spencer Hospital to verify any of the information given by me. I will provide documentation of this information upon request. I understand the information which I submit concerning my annual income and family size is subject to verification by Spencer Hospital. I also understand if the information which I submit is determined to be false, it will result in a denial of charity care status and that I will be liable for charges for services provided.

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