PLEASE PRINT

Patient Financial Assistance Program Application

Applicant’s Name: _____________________________________________

Address: ______________________________________________________

City: ______________________ State: _______ Zip: _____________

Telephone: (     ) ___________________________________________

Date of Birth: ________________________________________________

Family Members (List all family members living in household and their date(s) of birth. Children age 19 and over must
apply separately):

Name                                      Relationship   Date of Birth

______________________________________________   _____________

______________________________________________   _____________

______________________________________________   _____________

______________________________________________   _____________

______________________________________________   _____________

______________________________________________   _____________

Applicants must submit all required documents in the same mailing.

The following documentation is required to determine eligibility:

1. Proof of identity (Please bring and provide)

1. copies of photo ID
2. proof of address
3. social security cards of all family members on the application
4. birth certificates
5. resident cards, visas or passports

2. Proof of income (Submit all documentation that applies to your household)

• Pay stubs for most recent four weeks for each working member of household
• Unemployment or Workers Compensation
• Social Security benefit letter or bank statement, if you use Direct Deposit
• Pension statement description
• Most recent tax return filed. If you had a Low Income Tax Exemption and did not have to file a return, you will be required to sign a statement at the time you submit your application.

3. Other resources: (answer questions - circle yes or no)

A. Do you have a checking or savings account?

• YES (please provide three consecutive statements)
• NO

B. Do you have any other sources of income:

• YES (please attach letter with description)
• NO

C. Have you been recently denied medical coverage by the Department of Social Services (DSS)?

• YES (please attach denial letter)
• NO

I affirm by my signature below that the information contained on this application is true to the best of my knowledge. I agree to provide additional information as requested in order to inform St. Vincent’s promptly of any changes in my needs, income, living arrangements or address. Based on the determination of this application for reduced charges, I hereby agree to pay such fees at the time the service is rendered.

PLEASE NOTE: You may be required to apply for Medicaid assistance before your request can be approved.

___________________________________________________________

Applicant’s Signature

________________________________________________________

Relationship (if other than patient)

___________________________________________________________

Date

Please call for an appointment:

Phone (203) 576-6257

St. Vincent’s Medical Center Patient Access

2800 Main Street

Bridgeport, CT 06606

OFFICE USE ONLY

Discount % Approved _________________

Date Approved ________________________

Approval Signature ____________________