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To apply for Fort HealthCare’s Community Care program on outstanding balances for persons whose income is determined to be above 200% of the Community Services Administration poverty guidelines, the following information must be furnished. Financial information should include all income for applicant and spouse/co-guarantor. Please complete all areas using “None” where not applicable.

* Required Fields

Personal Information

Applicant's Name:*
Last Name
First Name
MI
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Date of Birth:*
Address:*
 
City:* State:* Zip:*
County:*
Home Phone Number:* - -
Alternate Number: - -

Spouse's/Co-guarantor's Information

Spouse's/Co-guarantor's Name:
Last Name
First Name
MI
Date of Birth:
(Same as above) Address:
 
City: State: Zip:
County:
Home Phone Number: - -
Alternate Number: - -

Other Information

Number of Dependent Children:*
Are you listed as dependent on someone's tax forms*

Employment Information

Applicant's Employer:
Address:
 
City: State: Zip:
Occupation:
Length of Employment:

Spouse's Employment Information

Spouse's Employer:
Address:
 
City: State: Zip:
Occupation:
Length of Employment:

Assets & Income

Gross Monthly Income
Applicant's Wages: $
Spouse's Wages: $
Social Security Income: $
Pension / Other Income:
Veteran Benefits: $
Child Support/Maintenance: $
Retirement: $
*Other Income : $

*Interest, dividends, income from rental property, estates and trusts; Unemployment compensation, workers’ compensations, public assistance

Please Submit the Following Documents

  • Copy of most recent tax return
  • Human Services written denial for medical assistance
  • Three most recent payroll stubs
A FHC representative will reach out to you for all relevant documents after submission

This is not applicable for persons whose income is at or up to 200% of the FPL.

Please fax to: 920-568-5296
Please mail to:
Fort HealthCare
ATTN: Financial Counselor
611 Sherman Avenue
Fort Atkinson, WI 53538
Please deliver to:
Fort Memorial Hospital
Financial Counselor’s Office
611 Sherman Avenue
Fort Atkinson, WI 53538

Please list any additional information pertinent to this application:

Preference for Fort HealthCare Monthly Installment Amount*

$