Financial Assistance Form - Madison Core Labs, LLC

Name *

First

Middle

Last

SECTION 1: PATIENT INFORMATION

Birth Date: *

Social Security #: *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Marital Status *

Spouse / Guarantor Name:

Are you a legal resident of the United States? *

SECTION 2: FINANCIAL ASSESSMENT

Monthly Income Source

Monthly Income, Patient

Monthly Income, Spouse

Total family Income

Monthly Income Source (copy)

Monthly Income, Patient

Monthly Income, Spouse (copy)

Total family Income (copy)

Monthly Income Source (copy) (copy)

Monthly Income, Patient

Monthly Income, Spouse (copy) (copy)

Total family Income (copy) (copy)

Monthly Income Source (copy) (copy) (copy)

Monthly Income, Patient (copy) (copy)

Current Monthly Gross Income of Patient.

Monthly Income, Spouse (copy) (copy) (copy)

Current Monthly Gross Income Amount for Spouse/Other.

Total family Income (copy) (copy) (copy)

Enter the total family income for 3 months prior to Date of Service.

Documentation

Copy of most recent pay stubs and income statements for previous 3 months.

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Social Security Award Letter

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Statements on Retirement/Pension benefits and/or Dividends/Interest, etc.

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Unemployment Benefit Letter, Workers' Compensation Benefit Letter

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Previous Years' Tax Return

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If you have no income, please provide an explanation of how you are meeting basic living needs.

recent Patient Unemployment

SECTION 3: FAMILY INFORMATION

Name of all family members including patient, their date of birth, and relationship to patient

Paragraph Text *

PATIENT CERTIFICATION *

ACKNOWLEDGE

By checking above, I CERTIFY the information I have provided is true to the best of my knowledge. I understand that my application for possible financial assistance may be denied if I do not cooperate with Madison Core Laboratories, LLC in supplying any additional requested information. I understand that the information that I submit is subject to verification, including credit reporting agencies, and subject to review by Federal and/or State agencies and others as required. I understand that this application pertains to laboratory charges only and not physician’s charges. I understand that completing the application and providing the documentation does not guarantee financial assistance will be provided.

INSURANCE ATTESTATION *

ACKNOWLEDGE

By checking above, I ATTEST that:

-I do not have private health insurance coverage, including but not limited to employer-sponsored plans, individual marketplace plans, or supplemental insurance.

-I do not have any government-funded health insurance coverage, including but not limited to Medicare, Medicaid, TRICARE, VA benefits, or any other federal or state health care program.

-I understand that this attestation is being provided for the purpose of determining eligibility for financial assistance. I acknowledge that providing false or misleading information may result in denial of services, revocation of financial assistance, or personal responsibility for all charges incurred.

-I agree to notify the laboratory or my healthcare provider immediately if my insurance status changes at any time.