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.
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.
|
First Name
|
Last
Name
|
Last 4
of
SSN
|
Date of
Birth
|
Relationship
|
(If Other, explain)
|
|
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
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 supplying my electronic signature it
constitutes a legal signature!
