Online Application "*" indicates required fields Welcome to your Kirby Medical Center 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: Untitled Pay Stubs (last two months) Proof of Income for All Income Sources (last two months) Bank Statements for Checking and Savings Accounts (last two months) Previous Year’s Tax Return State Letter (if applicable) After reviewing your submitted application, we may reach out to assist you with additional programs and insurance options available to you. Please get an electronic copy or pictures of your documents ready before starting your application. If you submit an incomplete application, we will reach out to you via mail for any additional information or documentation needed to process your application. Applicant Name* First Middle Last Social Security NumberSocial Security Number – OptionalDate of Birth*Address* Street Address City State ZIP / Postal Code Phone Number*EmailWhat is the APPLICANT’S gross monthly income from all sources? If none, enter 0.*This is for applicant income only. We will ask for other household member income later. The following questions regarding race, ethnicity, sex, and preferred language are OPTIONAL. Responses or non-responses will not have any impact on the outcome of the application. RaceEthnicitySexPreferred Language Including yourself, what is the total number of people living in your household?*Additional Household Member 1 – Name* First Last Additional Household Member 1 – Date of Birth*Additional Household Member 1 – Relationship to Applicant*What is Additional Family Member 1's total gross monthly income from all sources? If none, enter 0.*Additional Household Member 2 – Name* First Last Additional Household Member 2 – Date of Birth*Additional Household Member 2 – Relationship to Applicant*What is Additional Family Member 2's total gross monthly income from all sources? If none, enter 0.Additional Household Member 3 – Name* First Last Additional Household Member 3 – Date of Birth*Additional Household Member 3 – Relationship to Applicant*What is Additional Family Member 3's total gross monthly income from all sources? If none, enter 0.Additional Household Member 4 – Name* First Last Additional Household Member 4 – Date of Birth*Additional Household Member 4 – Relationship to Applicant*What is Additional Family Member 4's total gross monthly income from all sources? If none, enter 0.Additional Household Member 5 – Name* First Last Additional Household Member 5 – Date of Birth*Additional Household Member 5 – Relationship to Applicant*What is Additional Family Member 5's total gross monthly income from all sources? If none, enter 0.*Additional Household Member 6 – Name* First Last Additional Household Member 6 – Date of Birth*Additional Household Member 6 – Relationship to Applicant*What is Additional Family Member 6's total gross monthly income from all sources? If none, enter 0.Additional Household Member 7 – Name* First Last Additional Household Member 7 – Date of Birth*Additional Household Member 7 – Relationship to Applicant*What is Additional Family Member 7's total gross monthly income from all sources? If none, enter 0.If your household's total income is zero, please provide an explanation for how you are being supported. Banking and Current Asset Information Please provide the current balance/value in each of the following categories. If none, enter 0. Applicant's Savings Account(s) – Total Balance*Applicant's Checking Account(s) – Total Balance*Spouse/Other Savings Account(s) – Total Balance*Spouse/Other Checking Account(s) – Total Balance* Did the patient have health insurance at the time of hospital service?* Yes No Insurance Company Name*Insurance Phone Number*Insurance Group Number*Insurance Member ID*Are these services a result of a worker's compensation claim or motor vehicle accident?* Yes No Please check all that apply to you.If you have checked one or more boxes, you only need to submit your approval letter from the appropriate state department. No further financial documentation is needed. Illinois Medicaid (Title XIX) SNAP or WIC Low Income Home Energy Assistance Program (LIHEAP) Illinois Free Lunch and Breakfast Program Homeless 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. Pay StubsPlease upload paystubs for all income earners for the past 2 months, if applicable. 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 StatementsPlease upload any other statements you receive from income sources (Social Security, alimony/child support, unemployment, retirement/pension, etc.) for the past 2 months, if applicable. 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. State Assistance Approval Letter(s)Please upload your approval letter from the appropriate state department, if applicable. (Illinois Medicaid (Title XIX), SNAP or WIC, Low Income Home Energy Assistance Program (LIHEAP), Illinois Free Lunch and Breakfast Program, etc.) 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. Tax ReturnPlease upload your tax return from last year, if applicable. 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 StatementsPlease upload your statements from your checking and savings accounts for the past 2 months. 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 & BackPlease attach pictures or copies of the front and back of the medical insurance or Medicaid card effective at the time of service, if applicable. 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 formNumberThis 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 5380This field is hidden when viewing the formYearly Rate 15060This field is hidden when viewing the formTotal 12 Month Income Div by 12This field is hidden when viewing the formCalculated % FPL 12 MonthsSignature 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. 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.This field is hidden when viewing the formCompleted Completed Great! Please do not close your browser or leave this page until you see the confirmation page.NameThis field is for validation purposes and should be left unchanged.
