Financial Assistance Policy Application

 

 

 

GUARANTOR FINANCIAL STATEMENT

INSTRUCTIONS FOR COMPLETING THE FINANCIAL DATA FORM

 

 

The attached forms are used by DeSoto Regional Health System to determine if you qualify for financial assistance pertaining to your account(s) with our facilities. Please complete the forms according to the instructions. Also, please attached the required documentation. Only complete forms with all required documentation will receive consideration for enrollment in the Financial Assistance Program.

 

The following documentation is required in order to process your application:

1.     Copies of check stubs documenting your household income for three (3) months.

2.     Receipts for one (1) month of home mortgage or home rental payments.

3.     Copies of one (1) month of telephone bills, automobile payments, and utility bills.

4.     A copy of your most recently filed tax return.

 

Prior to returning your application to our office, please make sure that all requested information is complete, the form has been signed, and all documentation is attached. You may return your completed application in one of three ways: in person to a Business Office representative, by mail (to the address at the bottom of this page), or via email to stephaniewhitten@desotoregional.comYour information will be reviewed and you will be contacted regarding our decision, including the level of financial assistance that we will be able to offer. Should you have any questions regarding this process, you may contact our hospital at the number listed below. Please ask to speak to a Business Office representative regarding our Financial Assistance application process.

Thank you for the opportunity to serve you!



   

 

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