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Dear Patient,
Thank you for choosing a Resurrection Health Care hospital for your health care needs. We are committed to improving
the health and well being of everyone in our community. We are pleased to offer our financial assistance and charity care
program to help individuals and families who need assistance.
Enclosed is our Financial Assessment form. Please return the completed form with the requested documents by:
___________. If you have questions about the documents or do not have all the documents, please contact the Financial
Counselor at the phone number below. They will gladly assist you. Thank you for your cooperation.
Proof of Income (for each household member, provide all documents that exist and/or apply)
Pay stubs / proof of tips for past 2 months
If paid in cash, a signed letter from employer indicating terms of employment, including wages/salary, dates of
employment, current employment status, the availability of any health care benefits, etc.
If self employed, business records including income, expenses, liabilities and assets for past 2 months
Copies of checks or award letters from unemployment, Social Security or Veterans Administration
Copies of checks for child or spousal support
Proof of other income (for example, interest income, pension, rental income)
Copy of income tax return from most recent filing period
Notarized Confirmation of Support Letter
Disclosure of Assets (for each household member, provide all documents that apply)
Current statement from Checking and Savings Account(s), Certificate(s) of Deposit, Money Market Fund, Trust
Fund or Brokerage Statement
Please submit the requested documents to: Financial Counselor, St. Elizabeth Campus, 1431 N. Claremont, Chicago,
IL 60622-9882. Determinations of Eligibility for Financial Assistance are made within fifteen business days after
receiving all of the requested documents.
Completion of this form is not a guarantee of eligibility for Financial Assistance /Charity Care, or any other
program. Financial Assistance /Charity Care is only considered after all possible sources of coverage or potential
payment (for example, health insurance, Medicare, Medicaid, All Kids, liability insurance) have been exhausted.
Failure to provide all requested documents will result in non-approval.
Applicant’s
Last Name _______________________________First Name _______________________________M.I. ______Relationship to Patient__________
Gross Income $:
(Circle One: Wkly, Biwkly, Monthly) $ A
Gross Income $
(Circle One: Wkly, BiWkly, Monthly) $ B
I understand that qualifying for financial assistance is based on Resurrection Heath Care’s ability to verify the information I have provided. I
hereby certify, by signing below, that the information and documentation provided by me is complete and accurate to the best of my
knowledge.
Address City
Application Mailed to Patient Application Hand Delivered to Patient Application Completed Over Phone
_______________________________
Applicant (Print)
______________________________________________________
Application Number
The person named above applied for financial assistance to pay their hospital bill and has advised us that you either
contribute substantially to their support or you are their sole means of support. Please complete this form, have it
notarized and return it in the enclosed self-addressed envelope by: ___________________. For assistance finding a
Notary Public, please consult the Illinois Secretary of State’s Office at http://www.ilsos.gov/notary/ or by
calling 1-800 252-8980.
Note: Completing this form does not mean that you will be responsible for the patient’s hospital Bill
Thank you.
The type of support I / we provide is: (please complete all that apply)
___________________________________________________________________________
I / We, (print) _______________________________________ have been the sole/substantial support for the person
named above and, to the best of my / our knowledge, declare that this person has no other primary means of support.
______________________________ _______________________________
Signature 1 Signature 2 (if jointly providing support)
______________________________ _______________________________
Relationship to Applicant Relationship to Applicant
______________________________ _______________________________
Address, Street City
______________________________ _______________________________
Telephone Date
________________________________________________
Notary Public