A. Applicant Information

Applicant must be 18 or older. If patient is under 18 years of age, the parent/legal guardian is to complete the application under the parent/legal guardians name. List spouse, if applicable, and all children under 18 living in household under the "Dependent Information" section.

First Name

Middle Initial

Last Name

SSN

Date Of Birth

Marital Status

Phone Number

Preferred Contact Method

Address 1

Address 2

City

State

ZIP

B. Dependent Information

Click the button below to begin adding any 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.

C. Employment Information

$ $

D. Document Upload

Please upload any documentation that could support the income listed; possible items can include last year’s income tax return, W-2 forms, verification of Social Security and/or pension benefits or other proof of annual income. Please use the applicant's information when filling out the upload form.

You can also use your phone's camera to submit photos of documents!

If you are unable to upload your financial documentation, please mail to: MARION GENERAL HOSPITAL, PO BOX 1169, MARION, IN 46952

E. Potential Sources Of Income

a. Federal Taxable Wages (From Your Job)

b. Tips

c. Self-Employment Income

d. Unemployment Compensation

e. Social Security

f. Social Security Disability (SSDI)

g. Retirement or Pension Income

h. Capital Gains

i. Investment Income

j. Rental And Royalty Income

k. Excluded (Untaxed) Foreign Income

Name Of Bank

Checking Account Balance

Savings Account Balance

CD Balance

Estimated Home Value

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.

I understand that by checking the below box and supplying my electronic signature it constitutes a legal signature.