Online Application "*" indicates required fields URLThis field is for validation purposes and should be left unchanged.Welcome to your Gibson Area Hospital & Health Services online financial assistance application! In order to process your application, we need supporting documents to verify your financial situation. Required documents include any of the following that apply to your household: Most recent federal 1040 tax return Copy of two most recent pay stubs for all household members’ employment income. Copy of last two months bank statements Any other statements you receive from income sources (Social Security, alimony/child support, unemployment, retirement/pension, etc.)After reviewing your submitted application, we may reach out to assist you with additional programs and insurance options available to you. Please have electronic copies or pictures of your documents ready before starting your application. If you submit an incomplete application, we will reach out to you for any additional information or documentation needed to process your application. An incomplete application or missing documents may lead to your application being denied. Applicant Name* First Middle Last Date of Birth*Address* Street Address City State ZIP / Postal Code Phone Number*Email Address Applicant Guarantor Number* What is the Applicant's gross monthly income from all sources? If none, enter 0.* The following questions regarding race, ethnicity, sex, and preferred language are OPTIONAL, and responses or nonresponses will not have any impact on the outcome of the application.Race American Indian or Alaskan Native Black or African American Native Hawaiian or Other Pacific Islander White Ethnicity Hispanic or Latino Not Hispanic or Latino Sex Male Female Preferred Language English Spanish Polish Chinese Arabic Russian Urdu Other Other Language Did you have health insurance at the time of your service?* Yes No Insurance Company Name*Insurance Member ID*Insurance Group Number*If no, have you applied for Medicaid?* Yes No Is your service related to an auto accident?* Yes No If yes – Insurance Company NameInsurance Phone NumberInsurance Policy NumberIs your service related to a work injury?* Yes No If yes – Insurance Company NameInsurance Phone NumberInsurance Policy Number Including yourself, how many people are in your immediate family?*Immediate family includes the responsible party, their spouse if applicable, and all dependent children under 18 years old (natural or adoptive) who reside together.Please enter a number from 1 to 8.Additional Family Member 1 Name* First Last Additional Family Member 1 Date of Birth*Additional Family Member 1 Relationship to Applicant*What is Additional Family Member 1's total gross monthly income from all sources? If none, enter 0.Additional Family Member 2 Name* First Last Additional Family Member 2 Date of Birth*Additional Family Member 2 Relationship to Applicant*What is Additional Family Member 2's total gross monthly income from all sources? If none, enter 0.Additional Family Member 3 Name* First Last Additional Family Member 3 Date of Birth*Additional Family Member 3 Relationship to Applicant*What is Additional Family Member 3's total gross monthly income from all sources? If none, enter 0.Additional Family Member 4 Name* First Last Additional Family Member 4 Date of Birth*Additional Family Member 4 Relationship to Applicant*What is Additional Family Member 4's total gross monthly income from all sources? If none, enter 0.Additional Family Member 5 Name* First Last Additional Family Member 5 Date of Birth*Additional Family Member 5 Relationship to Applicant*What is Additional Family Member 5's total gross monthly income from all sources? If none, enter 0.Additional Family Member 6 Name* First Last Additional Family Member 6 Date of Birth*Additional Family Member 6 Relationship to Applicant*What is Additional Family Member 6's total gross monthly income from all sources? If none, enter 0.Additional Family Member 7 Name* First Last Additional Family Member 7 Date of Birth*Additional Family Member 7 Relationship to Applicant*What is Additional Family Member 7's total gross monthly income from all sources? If none, enter 0.If you are not receiving any income, please explain how you are being supported financially. Household Assets InformationPlease provide the current balance for the following categories. If none, enter 0.Did anyone in your household file taxes last year? Yes No Applicant Savings Accounts*Applicant Checking Accounts*Applicant Health Savings/Flex Spending Accounts*Does anyone else in the household have other bank accounts?* Yes No Spouse/Other Savings Accounts*Spouse/Other Checking Accounts*Spouse/Other Health Savings/Flex Spending Accounts* Uploading Documents This section is for attaching the documents we need to fully process your application and verify the information you provided. Please include copies of all of the following that apply to your household. Tax Returns*Please upload your most recent federal 1040 tax return, if applicable. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Pay Stubs*Please upload a copy of the two most recent pay stubs for all income earners, if applicable. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Bank Statements*Please upload your last two months of bank statements for all checking, savings, health savings, and flex spending accounts, if applicable. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Other Income Statements*Please upload any other statements you receive from income sources (Social Security, alimony/child support, unemployment, retirement/pension, etc.), if applicable. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Medical Insurance and/or Medicaid Card – Front & Back*Please attach pictures or copies of the front and back of your medical insurance or Medicaid card effective at the time of service, if applicable. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. This field is hidden when viewing the formFacility NameThis field is hidden when viewing the formTotal Household IncomeThis field is hidden when viewing the formTotal Household AssetsThis field is hidden when viewing the formFamily AdditionalsThis field is hidden when viewing the formTotal Family SizeThis field is hidden when viewing the formFamily Additional Total 5680This field is hidden when viewing the formYearly Rate 15960This field is hidden when viewing the formTotal 12 Month Income Div by 12This field is hidden when viewing the formCalculated % FPL 12 MonthsThis field is hidden when viewing the formAsset %Signature of Applicant*I certify that the above information is true and accurate to the best of my knowledge. I will apply and take any reasonable action needed to get assistance (Medicaid, Medicare, Insurance, etc.) to pay my hospital charges. Financial assistance is a source of last resort. Any other liability or possible payer will be exhausted prior to awarding assistance. I understand that this application is made so that the hospital can see if I am eligible for financial assistance based upon defined criteria.Spouse Signature (if applicable) Are You Ready to Submit Your Application?* No I’m Ready On a scale from 1-5, with 1 being HARD and 5 being EASY, how was your experience applying for Financial Assistance online?Please enter a number from 1 to 5.Great! Please do not close your browser or leave this page until you see the confirmation page.
