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
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Date of Birth:*
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: - -
 
(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: $
Property
Residence:*
Monthly Payment:* $ Owe: $ Equity: $
 
Other Properties:
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
Tax return
Medicaid Denial
Recent Payroll Stubs
(submit multiple files or one file)
Please fax to: 920-568-6033
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, 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*

$



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