Patient Assistance Program | Helena SurgiCenter

The Helena SurgiCenter offers a broad range of services which are provided with efficiency and sensitivity to the patient’s needs, both medically and financially. It is the policy of the Helena SurgiCenter to provide medical care to needy patients. Your account balance may be adjusted if you qualify. Below is a financial statement that we ask you to complete to help us determine your eligibility. Proof of income must be included with the financial statement when it is returned to the Business Office.

Income will be annualized based upon documentation provided by you and will take into consideration seasonal employment and temporary increases and/or decreases of income and net assets.

This application (financial statements and accompanying proof of income) must be returned to the Helena SurgiCenter within fourteen working days. If additional time is required due to your medical condition, or if assistance with the financial statement is needed, contact the Business Office Coordinator at the Helena SurgiCenter. Please send the completed information form to us in the enclosed self-addressed envelope.

The SurgiCenter will notify you in writing of the final determination of eligibility within fourteen working days of receipt of the financial statement and proof of income documentation.

All information relating to the application for Patient Assistance will be kept
confidential.

Financial Assistance Application

Account Number *

Department Location *

Guarantor’s Last Name, First * Guarantor's Date of Birth * Guarantor's Social Security Number * Guarantor's Source of Income *EmployedRetiredUnemployedDisabled

Spouse’s Last Name, First Spouse's Date of Birth Spouse's Social Security Number Spouse's Source of Income EmployedRetiredUnemployedDisabled

Guarantor's Address *

City *

Zip code *

Guarantor's Email *

Home Phone Number

Cell Phone Number *

Dependent's Last Name, First

Date of Birth

Dependent's Last Name, First

Date of Birth

Dependent's Last Name, First

Date of Birth

Dependent's Last Name, First

Date of Birth

Dependent's Last Name, First

Date of Birth

Dependent's Last Name, First

Date of Birth

INCOME (List all Monthly Gross Income)	Applicant	Spouse	Other	Total
Gross Wages from Paycheck
Farm or Self Employed
Social Security SSI/SSDI
Unemployment Compensation
Workers’ Compensation
Alimony
Child Support
Pension/Retirement
Dividends/Interest/Rent Income
Education Grants/Loans
Inheritance
Oil & Mineral Royalties/Land Lease
Native American Income
Income Tax Refunds: FederalState
Settlement Income: Workers' CompBodily InjuryMotor Vehicle AccidentLawsuitOther
Other Income
TOTAL

Monthly Expenses	Amount
Rent
Groceries/Household Products
Lights and Heat
Phone (Cell and Home)
Water & Sewer
Gasoline
Insurance (Health, Home, Auto, Life, Renter’s, Etc.)
Child Care
Child Support
Clothing
Entertainment Including TV, Internet, Movies, Etc.
Prescriptions
Other
Total

Please use additional space, if needed.

Proof of Income Must Include:

Payroll check stubs for the last 3 months
Verification of eligibility for unemployment compensation
Notice of ineligibility from Medicaid, state medical, crime victims, etc.
Copy of latest Federal (IRS) income tax return
Other data necessary to determine your eligibility

Upload your proof files here

PLEASE READ CAREFULLY
I authorize a representative of the Helena SurgiCenter to obtain personal, financial or medical information from any source deemed necessary to determine an acceptable financial agreement and/or assisting me in obtaining financial assistance. In so authorizing, I release any person(s) or business from any or all liability connected with said release.
I will make application for assistance (Medicaid, Medicare, Insurance, etc.) which may be available for payment of my hospital expenses, and I will take any action reasonably necessary to obtain such assistance and will assign or pay to the hospital the full amount recovered.
Please check if account balance is a financial hardship.I request that the Helena SurgiCenter make a written determination of my eligibility for uncompensated services at the Helena SurgiCenter. I understand that the information which I submit concerning my annual income, net assets and number of residents in my household is subject to verification by the Helena SurgiCenter. I understand that if the information which I submit is determined to be untrue, such a determination will result in a denial of financial assistance, and that I will be liable for charges for services provided.

Signature *

Date of Request *