Spencer Hospital Patient Payment Assistance Application

• Single
• Married
• Divorced
• Separated
• Other

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

• Weekly
• Biweekly
• Monthly
• Other

• Weekly
• Biweekly
• Monthly
• Other

Applicant Income Information

Spouse Income Information

• Rent
• Mortgage

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.