Insurance and Policy Information
Responsible Party (if different from patient):
I am supplying the following information so that an accurate determination can be made of my financial situation. The monthly dollar amount is from all sources, including Social Security benefits, annuities, dividends, etc. Attached is verification of my employment/unemployment status and copies of my federal tax returns or W-2 forms for the previous two years, as well as other information I feel should be considered in determining my ability to pay.
Self Monthly Income
Spouse Monthly Income