Community Care - Financial Questionnaire

Fort Memorial Hospital
611 Sherman Avenue East
Fort Atkinson, WI 53538
(920) 568-5000 | La linea de mensajes: (920) 568-5001

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In order to apply for Fort HealthCare’s Community Care program on outstanding balances, the following information must be furnished. Financial information should include all assets, liabilities and income for applicant and spouse. Please complete all areas using “None” where not applicable.

* Required Fields

Personal Information

Applicant's Name:*	Last Name First Name MI
Date of Birth:*
Social Security Number:*	- -
	Check here if no Social Security Number.
Address:*

City:*	State:* Zip:*
County:*
Home Phone Number:*	- -
Alternate Number:	- -

Spouse's Information

Spouse's Name:	Last Name First Name MI
Date of Birth:
Social Security Number:	- -
	Check here if no Social Security Number.
(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* Yes No

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:	$

Property
Residence:*	Own Rent
Monthly Payment:*	$	Owe:	$	Equity:	$

Other Properties:	Own Rent
Monthly Payment:	$	Owe:	$	Equity:	$
Describe Property:

Motor Vehicles (Car, Boat, ATV, etc...), (Year and Make)
1.		Owe:	$	Equity:	$
2.		Owe:	$	Equity:	$

Assets / Savings
Savings:	$	Bank Name:
Checking:	$	Bank Name:
Cash on Hand:	$
Retirement (401K, 403B):	$
Stocks & Bonds:	$
Cash Value of Life Insurance:	$

Please Submit the Following Documents

Copy of most recent tax return
Human Services written denial for medical assistance
Three most recent payroll stubs

Via this form:

Tax return
Medicaid Denial
Recent Payroll Stubs (submit multiple files or one file)

Via fax:

Please fax to: 920-568-6033

Via mail:

Please mail to:

Fort HealthCare
ATTN: Financial Counselor
611 Sherman Avenue
Fort Atkinson, WI 53538

Drop off:

Please deliver to:

Fort Memorial Hospital
Financial Counselor’s Office, next to the Gift Shop
611 Sherman Avenue
Fort Atkinson, WI 53538

Please list any additional information pertinent to this application:

Preference for Fort HealthCare Monthly Installment Amount*

By checking this box, I represent that this statement of my financial condition is true & complete and authorize Fort HealthCare or its agents, to verify the information obtained in this statement and obtain additional information concerning my financial condition and furnish the same to others. I understand that it is a federal crime punishable by fine or imprisonment or both to knowingly make any false statements concerning any of the following information as applicable under provisions of Title 18, United States code, Section 1014. I agree to notify Fort HealthCare in writing, of any changes that materially affects the accuracy of this statement. This statement is the property of Fort HealthCare.

Fort Memorial Hospital

Fort Memorial Hospital

611 Sherman Avenue East, Fort Atkinson, WI 53538

611 Sherman Avenue East,
Fort Atkinson, WI 53538

(920) 568-5000

La linea de mensajes: (920) 568-5001