A. Patient & Family Information

Dependent Information

Number of dependents in household including patient and the following individuals who live with the patient. Patient’s spouse, patient’s biological, adoptive or step children under the age of 18.


B. Employement Information


C. Assets


VERIFICATION AND AUTHORIZATION FOR RELEASE OF INFORMATION

THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE

I understand that the statements I have made on this form are subject to investigation and verification. I understand that I will be asked to provide proof of the information which I have given on this form, and I agree to help the Hospital obtain the necessary verifications. I hereby authorize the release of wage information, financial information from banks and other financial institutions and from the Department of Health and Human Services to the Hospital.