Financial Aid Law (FAL)
Attachment B
Sample Application
Name: ___________________________________________________________________________
Address: _________________________________________________________________________
________________________________________________________________________________
Phone: __________________________________________________________________________
Family size / number in household: ____________________________________________________
| Patient Income | Spouse Income | |
|---|---|---|
| Wages | ||
| Social Security payment | ||
| Unemployment compensation | ||
| Disability | ||
| Workers compensation | ||
| Alimony/child support | ||
| Dividends/interest/rentals | ||
| All other income | ||
| Total |
I affirm that the above information is true, complete, and correct to the best of my knowledge.
Signed ________________________________________________________ Date ____________________________
If you have questions or need help completing this application, call [PERSON OR DEPARTMENT] at [DIRECT NUMBER].
If you have received a bill or bills from the hospital, check here: ________
You do not have to make any payment to the hospital until the hospital sends you a letter with its decision on your application.
[DEPARTMENT]
[HOSPITAL]
[ADDRESS]
