Financial Statement Instructions
PATIENT INFORMATION: Complete all blocks, if no spouse/partner, write “N/A” in the block for Spouse’s Name.
RESPONSIBLE PARTY INFORMATION: This is the person who is responsible for the bill, if the Responsible Party is the patient, write “ Same as Patient” in the block for Name. If someone other than the patient is Responsible Party complete all blocks.
DEPENDENTS: List all dependents in this section (dependent children living in the home). Include full name, age, relationship and Social Security Number. IF DEPENDENT CHILD IS ELIGIBLE FOR MEDICAID OR BLUE CROSS ALL KIDS INSURANCE, YOU MAY WRITE INSURANCE ID NUMBER IN THE SOCIAL SECURITY NUMBER BLOCK.
ASSISTANCE: This includes programs such as Food Stamp Program, Social Security Disability and Supplemental Security Income. Circle response, YES or NO. Provide name of program(s), date assistance was applied for and status if known.
GROUP INSURANCE INFORMATION: This section must be completed. If your employer offers medical insurance and you are not enrolled you must provide an explanation.
BUSINESS OFFICE USE ONLY: This section is reserved for Business Office recommendation.
INCOME: All blocks must the completed. If any block does not apply, write “N/A” in the block. Include ALL household income per month. If you receive income that is not identified you may write in type of income and amount in “Other” blocks.
BUSINESS OFFICE USE ONLY: This section reserved for Business Office.
EXPENSES: All blocks must be completed. If any block does not apply, write “N/A” in the block.
- Mortgage – Monthly mortgage payment, if you own your home write “Own”
- Primary Telephone – Include total of land line and cell phones
- Groceries – amount spent each month in addition to Food Stamps received
- Student Loans – Monthly amount paid, if deferred, write “Deferred”
PROPERTY / ASSETS: If you rent, write “N/A” as Value $. If you own or are buying your home write in value and brief description of property (EX: Brick or wood frame, number of bedrooms, number of baths, acreage).
OTHER ASSETS: If no other assets write “N/A” in this section. If you have non-essential assets / collectibles to list, include value and description.
VEHICLE: Complete each block (Make, Model, Year) whether owned or paying note.
SIGN AND DATE