Online Application "*" indicates required fields Welcome to your Cameron Memorial Community Hospital online financial assistance application! In order to process your application, we need supporting documents to verify your financial situation. Required documents include any of the following that apply to your household: Most Recent Pay Stubs (last four weeks) Last Year’s Personal & Business Tax Returns & W-2’s Alimony/Child Support Records Social Security Benefit Letter(s) Unemployment Statement Veterans Benefit Letter Bank Statements (last two months)After reviewing your submitted application, we may reach out to assist you with additional programs and insurance options available to you. Please get an electronic copy or pictures of your documents ready before starting your application. If you submit an incomplete application, we will reach out to you for any additional information or documentation needed to process your application. Do you have your proof of income documents ready?* Yes No I will mail in or drop off my proof of income documents at Cameron Memorial Community Hospital in the next 10 days.*The address to send or drop off your documents to is: Cameron Memorial Community Hospital, Attn: Patient Financial Services, 416 E. Maumee Street Angola, IN 46703 Yes Patient InformationGuarantor NumberService DatesName* First Last Date of Birth*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What county do you live in?*Are you a legal resident of the United States? Yes No Social Security NumberMarital Status* Single Married Divorced Phone Number Employer Information Is anyone in the household employed? Yes No Please enter the employer names and which member of the household works there for the two main sources of employment income, if applicable.Employer NameAbove employer name is for: Patient Spouse Other Employer NameAbove employer name is for: Patient Spouse Other Insurance InformationAt your service date did you have any plan, group or insurance that reimburses medical expenses?* Yes No Insurance Company NameInsurance Effective DateSubscriber NameInsurance Member IDInsurance Group Number The following “Authorized Representative for Health Coverage Form” is required with all Financial Assistance Applications. We have prefilled out the sections that are required, but need you to review the information and sign off so our partner, ClaimAid, can apply for health insurance coverage or other resources that may be available to cover the cost of your care. Authorized Representative for Health Coverage FormIf you want someone to act on your behalf in applying for benefits and/or act for you on an ongoing basis, this form must be completed. Be sure to select the function(s) that the representative is being authorized to do. You can select more than one representative and choose the same or different functions. The representative may be an individual or an organization. Complete ONE form per authorized representative. Both you and your representative must sign and date this form.Name of RepresentativeClaimAid works with patients to assist with getting reimbursement for medical services with quick, accurate, and compassionate representation throughout the eligibility determination process.Check association with applicant/recipient*ClaimAid is an Eligibility Assistance Company. Eligibility Assistance Company Select the function(s) the authorized representative will do:*ClaimAid needs to be able to apply for benefits and take care of ongoing redeterminations on your behalf. Apply Sign application and be interviewed. Provide all required proof of information necessary to determine eligibility for benefits. Receive the Notice of the application decision. Speak on applicant’s behalf at a hearing if the application decision is appealed.Report changes. Attend periodic redeterminations. Receive the appointment notices and any redetermination mail-in forms. Speak on applicant’s behalf at a hearing if the application decision is appealed. Note: Do not check this function if the representative will not continue to act on recipient’s behalf after the application decision has been made.* Ongoing Report changes. Attend periodic redeterminations. Receive the appointment notices and any redetermination mail-in forms. Speak on applicant’s behalf at a hearing if the application decision is appealed. Note: Do not check this function if the representative will not continue to act on recipient’s behalf after the application decision has been made.Applicant/Recipient NameApplicant/Recipient Date of BirthApplicant/Recipient last 4 digits of Social Security NumberSignature*I authorize this representative to act for me in taking care of the functions and program eligibility process which I have checked above. (If applicant/recipient is medically incapable to sign authorization, provide medical documentation.) I understand that I am responsible for the information anyone acting as my authorized representative gives, including any information that may be incorrect. I also understand that if at any time I wish to stop the person(s) I chose from being my authorized representative, it is my responsibility to contact the Division of Family Resources. Household Information Including yourself, what is the total number of people living in your household?*Immediate family includes the responsible party, their spouse if applicable, and all dependent children under 18 years old.Please enter a number from 1 to 8.Additional Household Member 1Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 2Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 3Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 4Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 5Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 6Name* First Last Date of Birth*Relationship to Patient*Additional Household Member 7Name* First Last Date of Birth*Relationship to Patient* Household Income Information Please provide the total monthly gross income for each of the following categories. If none, enter 0.Patient Monthly Employment Income*Patient Monthly Self-Employment Income*Patient Monthly Alimony/Child Support Income*Patient Monthly Pension Income*Patient Monthly Social Security Income*Patient Monthly Dividends, Interest, Rental Income*Patient Monthly Unemployment Insurance, Workers' Compensation Income*Patient Monthly Veterans Benefits Income*Patient Other Monthly Income*This field is hidden when viewing the formTotal patient current monthly incomeSpouse/Other Monthly Employment Income*Spouse/Other Monthly Self-Employment Income*Spouse/Other Monthly Alimony/Child Support Income*Spouse/Other Monthly Pension Income*Spouse/Other Monthly Social Security Income*Spouse/Other Monthly Dividends, Interest, Rental Income*Spouse/Other Monthly Unemployment Insurance, Workers' Compensation Income*Spouse/Other Monthly Veterans Benefits Income*Spouse/Other Other Monthly Income*This field is hidden when viewing the formTotal Spouse/other current monthly incomeIf you are not receiving any income, please explain how you are being supported financially.This field is hidden when viewing the formTotal monthly family incomeThis field is hidden when viewing the formTotal Spouse/other current monthly incomeThis field is hidden when viewing the formTotal monthly family Self-Employment IncomeThis field is hidden when viewing the formTotal family monthly Alimony/Child Support IncomeThis field is hidden when viewing the formTotal family monthly Pension IncomeThis field is hidden when viewing the formTotal family monthly Social Security IncomeThis field is hidden when viewing the formTotal family Monthly Dividends, Interest, Rental IncomeThis field is hidden when viewing the formTotal family Unemployment Insurance, Workers' Compensation IncomeThis field is hidden when viewing the formTotal family Veterans Benefits IncomeThis field is hidden when viewing the formTotal family Other Monthly IncomeThis field is hidden when viewing the formTotal family Other Monthly Income Assets InformationPlease provide the total balance for the following categories. If none, enter 0.Patient Checking Accounts*Patient Saving(s) Accounts*Patient HSA/FSA Accounts*This field is hidden when viewing the formTotal Patient AssetsSpouse/Other Checking Accounts*Spouse/Other Saving(s) Accounts*Spouse/Other HSA/FSA Accounts*This field is hidden when viewing the formTotal Spouse/Other Assets Expenses InformationAbout how much do you spend each month on the following expenses? If none, enter 0.HousingAutoInsuranceElectric/GasHealth InsuranceMedicalFuelHousehold ExpensesCredit CardsCell PhoneLandlineCable TVOtherExpense CategoryOtherExpense Category Uploading Documents This section is for attaching the documents we need to fully process your application and verify the information you provided. Please include copies of all of the following that apply to your household. Pay StubsPlease upload last 4 weeks of paystubs for all income earners, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10. Medical Insurance and/or Medicaid Card – Front & BackPlease attach pictures or copies of the front and back of your medical insurance or Medicaid card effective at the time of service, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10. Tax Returns & W-2'sPlease upload last year’s complete income tax return & W-2 form, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10. Alimony/Child Support RecordsPlease upload alimony/child support records, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10. Unemployment StatementPlease upload unemployment statement, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10. Social Security Benefit LetterPlease upload any social security benefit letter(s), if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10. Veterans Benefit LetterPlease upload veterans benefit letter, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10. Bank StatementsPlease upload the past 2 months of your bank statements from your checking and savings account(s), as well as any Health Savings, Cash App, PayPal or Venmo statements, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, psd, Max. file size: 50 MB, Max. files: 10. This field is hidden when viewing the formFamily Total = FeesThis field is hidden when viewing the formFamily Total = Self EmployementThis field is hidden when viewing the formFamily Total = Child Support or AlimonyThis field is hidden when viewing the formFamily Total = SSN/PensionsThis field is hidden when viewing the formFamily Total = Dividends, interest, rental incomeThis field is hidden when viewing the formFamily Total = Unemployment Ins, Workers' CompensationThis field is hidden when viewing the formFamily Total = Veterans BenefitsThis field is hidden when viewing the formFamily Total = Other IncomeThis field is hidden when viewing the formPatient Gross Totals = Current Monthly IncomeThis field is hidden when viewing the formPatient/Other Gross Totals = Current Monthly IncomeThis field is hidden when viewing the formTotal Family Gross Totals = Current Monthly IncomeThis field is hidden when viewing the formTotal Patient AssetsThis field is hidden when viewing the formTotal Spouse/Other AssetsThis field is hidden when viewing the formFamily AdditionalsThis field is hidden when viewing the formTotal Family SizeThis field is hidden when viewing the formFamily Additional Total 5380This field is hidden when viewing the formYearly Rate 15060This field is hidden when viewing the formTotal 12 Month Income Div by 12This field is hidden when viewing the formCalculated % FPL 12 MonthsSignature*I understand that the information I provide to CMCH will be subject to verification. If necessary, I give CMCH permission to access my credit history. I also understand that CMCH may ask me for more information, if necessary to determine my eligibility, e.g. proof of assets, bank statements, HSA statements, or a denial letter issued by Medicaid. This request may be denied if I do not submit the required documentation, reserve the right to reverse any adjustment if any payment is released. I have read this application carefully and all the information I have represented is accurate and true.Relationship to patient (if not self) Are You Ready to Submit Your Application?* No I’m Ready On a scale from 1-5, with 1 being HARD and 5 being EASY, how was your experience applying for Financial Assistance online?Please enter a number from 1 to 5.Great! Please do not close your browser or leave this page until you see the confirmation page.PhoneThis field is for validation purposes and should be left unchanged.