INSTRUCTIONS FOR COMPLETING APPLICATION

Transcripción

1 INSTRUCTIONS FOR COMPLETING APPLICATION Date applicatin given: Guarantr # Name: Please review the fllwing payment ptins that are available t yu that can help settle yur accunt: Payment in full upn receipt Payment plan t pay in full within 6 mnths Pssible eligibility in gvernment assisted prgrams Review fr assistance with required cmpleted financial Infrmatin frms T review yur accunt(s) fr assistance, we request that yu cmplete the enclsed Financial Infrmatin frms and return them t us within 10 days. If nt received in 10 days, the balance n yur accunt is due immediately. Thank yu. 1. Please send prf f all types f husehld incme fr all parties living in the husehld. Sme examples wuld be: prf f incme frm jb, child supprt, unemplyment benefit histry, letter f supprt and/r retirement/pensin incme. 2. If yu are receiving Scial Security r disability incme, please send a cpy f yur check r a letter frm Scial Security shwing mnthly incme r a cpy f yur bank statement shwing the US Treasury depsit. 3. If self-emplyed, please cmplete the self-emplyment dcument shwing yur incme and expenses. 4. A ntarized letter f supprt is t be cmpleted if there is smene prviding basic living needs fr yu. 5. Please call the number n the business card t btain the dates f incme that will be needed in rder t prcess yur applicatin. Return cmpleted applicatin t: Valley Physician Enterprise 314 Hpe Drive Winchester, VA This is an attempt t cllect a debt, and any infrmatin btained will be used fr that purpse.

2 Phne # Fax # FINANCIAL INFORMATION SHEET ( FIS ) Patient Name Accunt Date Guarantr C-Guarantr Spuse First Name Middle Initial Last Name First Name Middle Initial Last Name Sc. Sec # Date f Birth # f Dependent Children (living in hme) & Ages Sc. Sec # Date f Birth # f Dependent Children (living in hme) & Ages Married (legally) Separated hw lng? Unmarried (include single, divrced, widwed) Present Address Married (legally) Separated hw lng? Unmarried (include single, divrced, widwed) Present Address ) Hw Lng: years mnths ) Hw Lng: years mnths Previus Address (If less than tw years at present) Previus Address (If less than tw years at present) Buying Own Renting Live with parents / family / friend Buying Own Renting Live with parents / family / friend Emplyer Name & Address Emplyer Name & Address Phne: Hw Lng yrs ms Other Incme Surce $ Previus Emplyer (if less than 1 year at present emplyer) Phne: Psitin Grss Mnthly Incme Hw Lng yrs ms. Psitin Grss Mnthly Incme Other Incme Surce $ Previus Emplyer (if less than 1 year at present emplyer) ) ) Last Day at this Jb: Last Day at this Jb: Nearest relative nt living with yu: Relatinship: Nearest relative nt living with yu: Relatinship: Name Name Address Address Phne: ( ) Phne: ( ) The undersigned certify that all statements made herein are true and cmplete and t be relied upn by this facility and/r its assignee and are made t induce this facility and/r its assignee t extend credit. The undersigned authrizes this facility and/r its assignee t investigate their credit, verify emplyment histry and release infrmatin abut this facility and/r assignees credit experience with them. Guarantr Date C-Guarantr Date

3 ACCOUNT(S) If n emplyment/incme, what was yur last day f emplyment (self) (spuse) Are yu r yur spuse receiving unemplyment benefits? Yes N If yes, hw much per mnth? $ (enclse cpy f Benefit Payment Histry frm Emplyment Cmmissin) Did yur husehld receive any mney frm anyplace else? Yes N If yes, frm where hw much per mnth $ (Enclse prf fr dates listed abve) frm where hw much per mnth $ (Enclse prf fr dates listed abve) If n incme listed, hw are yu paying yur expenses? Hw many dependents/exemptins did yu claim n last year s tax return? (Include self, spuse, children) Will there be a change in number f dependents/exemptins claimed n this year s tax return? If s, explain changes MONTHLY HOUSEHOLD EXPENSES I. List all lans/credit cards T Whm Indebted Mnthly Payment Present Balance Current: Y/N? 1. Rent / Mrtgage: 2. Vehicle Lan: II. Mnthly Husehld Expenses Fd: Medicine: Car Expense: (Gas/Repairs) Life Insurance: Electricity: Aut Insurance: Water: Hmewners Ins Phne: Health Insurance: Gas: (Heat/Prpane) Cable: Other: ALL INFORMATION RELEASED IS CONFIDENTIAL

4 ACCOUNT (S) EMPLOYEE PAYROLL VERIFICATION SHEET HOJA DE VERIFICACIÓN DE EMPLEO EMPLOYEE NAME SOCIAL SECURITY # NOMBRE DEL EMPLEADO # DE SEGURO SOCIAL EMPLOYER S NAME PHONE # NOMBRE DE LA COMPAÑÍA: DE TELÉFONO: ADDRESS FAX # DIRECCIÓN: N. DE FAX Beginning Date f Emplyment: Cuánd Empezó a Trabajar Last Date f Emplyment (if applicable): Últim día de Emple (Si ya n trabaja allí) MONTH Mes JANUARY/Ener FEBRUARY/Febrer MARCH/Marz APRIL/Abril MAY/May JUNE/Juni JULY/Juli AUGUST/Agst SEPTEMBER/Septiembre OCTOBER/Octubre NOVEMBER/Nviembre DECEMBER/Diciembre GROSS WAGES Salari Brut NET WAGES Salari Net YEAR-TO-DATE WAGES Salari Ganad a la Fecha TOTAL: If this persn receives tips, please estimate an average day s tip: $ per day tips. Sí este emplead recibe prpinas, favr estimar el prmedi diari de prpinas: $ en prpinas pr día. Pay is received n which day f the week?/en qué día de la semana se hacen ls pags? Pay is received as fllws; please check ne: /Ls pags se reciben en la siguiente frma: Weekly/Semanal Bi-Weekly/Cada ds semanas Semi-mnthly/Ds Veces pr Meses Mnthly/Mensual I,, hereby give my emplyer the authrizatin t release the abve infrmatin. Y,, autriz a la Cmpañía para que de la infrmación slicitada arriba. Emplyer Signature: Firma del Representante de la Cmpañía: PLEASE FAX OR MAIL COMPLETED FORM BACK TO: Favr re enviar pr crre pr fax esta frma a: Date: Fecha: Physician Billing Valley Physician Enterprise 314 Hpe Drive Winchester, VA Telephne: Fax:

5 ACCOUNT # CUENTA # SELF-EMPLOYMENT INCOME/EXPENSES RECORD RECORD DE INGRESOS Y GASTOS PARA PERSONAS QUE TRABAJAN POR SU CUENTA NAME: SOCIAL SECURITY # NOMBRE N. DE SU SEGURO SOCIAL Mnth & Year / Mes y Añ January/Ener February/Febrer March/Marz April/Abril May/May June/Juni July/Juli August/Agst September/September Octber/Octubre Nvember/Nvembre December/Diciembre Self-Emplyment Incme (Ttal fr mnth) / Ingress pr Mes Self-Emplyment Expenses (Ttal fr mnth) / Gasts pr Mes I / We d swear that all the abve incme/expense infrmatin is true and crrect. / Y / Nstrs quienes firmams esta hja, jurams que la infrmación dada es verdadera y crrecta. X Date/Fecha Signature X Date/Fecha Signature

6 ACCOUNT(S) NOTARIZED LETTER OF SUPPORT This letter is t advise that I,, prvided fr basic living needs and expenses frm thrugh fr, wh is applying fr a federal assistance prgram. All infrmatin prvided is subject t audit fr verificatin purpses. I am nt respnsible fr any medical bills fr this persn. I d swear that the abve infrmatin is true. Signature Date State f City/Cunty f The freging instrument was acknwledged befre me this by Persn seeking acknwledgement day f, NOTARY PUBLIC MY COMMISSION EXPIRES: CARTA NOTARIZADA DE MANTENIMIENTO Cn ésta carta les infrm de que Y,, me hag carg de ls gasts necesaris y básics para vivir de, quien está slicitand ayuda en el prgrama federal, desde, 20. Entiend que tda la infrmación que dy estará sujeta a auditria cn el prpósit de verificar su veracidad. N me hag respnsable de ningún pag pr servicis médics. Jur que ésta infrmación es verdadera. Firma Fecha State f City/Cunty f The freging instrument was acknwledged befre me this by Persn seeking acknwledgement day f, NOTARY PUBLIC MY COMMISSION EXPIRES: