Online Application "*" indicates required fields X/TwitterThis field is for validation purposes and should be left unchanged.Welcome to your Sarah Bush Lincolns 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 Most recent bank statements – checking and savings account information Most recent tax forms. The last two years tax forms are needed for those who are self-employed. Most recent check stub(s) from all jobs Verification of all other income Public Aid approval or denial letter if applicable – pregnant, dependent children, disabled, blind, over age of 65 Unemployment check stub listing start date and amount Divorce decree stating child support paid or alimony and child support received Letter from public programs (Social Security, Veterans, Public Aid) listing amount received Written verification from employer One other reasonable form of income verification Investments – CDs, stocks, bonds, retirement account statements W-2 or 1099 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. Financial applications without supporting documents to verify your financial situation will not be processed. Applicant Name* First Last Date of Birth*Address* Street Address City State ZIP / Postal Code Social Security NumberNot required if you are uninsured. Not required for National Health Service Corps sites.Phone Number*Email 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 2 – Name* First Last Additional Household Member 2 – Date of Birth*Additional Household Member 3 – Name* First Last Additional Household Member 3 – Date of Birth*Additional Household Member 4 – Name* First Last Additional Household Member 4 – Date of Birth*Additional Household Member 5 – Name* First Last Additional Household Member 5 – Date of Birth*Additional Household Member 6 – Name* First Last Additional Household Member 6 – Date of Birth*Additional Household Member 7 – Name* First Last Additional Household Member 7 – Date of Birth*If your household's total income is zero, please provide an explanation for how you are being supported. Employment InformationIs Applicant/Patient/Spouse/Partner employed?* Yes No Patient's Employer NamePatient's Employer Address Street Address City State Zip Code Spouse/Partner/Guarantor Employer NameSpouse/Partner/Guarantor Employer Address Street Address City State Zip Code Did the patient have health insurance at the time of service?* Yes No Insurance Company Name*Did the patient have any of the following types of coverage at the time of service?* Medicaid Medicare No Medicare Supplement Name* 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. Bank StatementsPlease upload your most recent statements from your checking and savings accounts. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Max. file size: 50 MB, Max. files: 10 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 most recent tax return, if applicable. (The last two years tax forms are needed for those who are self- employed.) Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Max. file size: 50 MB, Max. files: 10 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 StubsPlease upload two most recent pay stubs from all jobs for all income earners, if applicable. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Max. file size: 50 MB, Max. files: 10 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. Verification of all other incomePlease upload documentation of any income you receive outside of your primary employment, if applicable. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Max. file size: 50 MB, Max. files: 10 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. Public Aid Approval/Denial LetterPlease upload your public aid approval or denial letter (pregnant, dependent children, disable, blind, over age 65), if applicable. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Max. file size: 50 MB, Max. files: 10 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. Unemployment Check StubPlease upload most recent unemployment statement listing start date and amount, if applicable. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Max. file size: 50 MB, Max. files: 10 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. Divorce Decree/Alimony/Child Support RecordsPlease upload divorce decree stating child support paid or alimony and child support recieved, if applicable. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Max. file size: 50 MB, Max. files: 10 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. Public Program LetterPlease upload most recent letter from any public programs (Social Security/Disability, Veterans, Public Aid) benefit letter, if applicable. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Max. file size: 50 MB, Max. files: 10 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. Employer VerificationPlease upload written verification from employer, if applicable. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Max. file size: 50 MB, Max. files: 10 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. Investment StatementsPlease upload your investment statements – CDs, stocks, bonds, retirement accounts, if applicable. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Max. file size: 50 MB, Max. files: 10 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. W-2 or 1099Please upload your W-2 or 1099, if applicable. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Max. file size: 50 MB, Max. files: 10 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. Acceptable files include: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd Max. file size: 50 MB, Max. files: 10 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 formTotal Household Monthly IncomeThis field is hidden when viewing the formAnnual IncomeThis field is hidden when viewing the formTotal 12 Month Income Div by 12This field is hidden when viewing the formYearly Rate 15960This field is hidden when viewing the formTotal Family SizeThis field is hidden when viewing the formFamily AdditionalsThis field is hidden when viewing the formFamily Additional Total 5680This field is hidden when viewing the formCalculated % FPLThis field is hidden when viewing the formNumberSignature of Applicant*I certify that the information in this application is true and correct to the best of my knowledge. I will apply for any state, federal or local assistance for which I may be eligible to help pay for this hospital bill. I understand that the information provided may be verified by the hospital, and I authorize the hospital to contact third parties to verify the accuracy of the information provided in this application. I understand that if I knowingly provide untrue information in this application, I will be ineligible for financial assistance, any financial assistance granted to me may be reversed, and I will be responsible for the payment of the hospital bill. 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.Please let us know what would have made your experience better.*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.
