Financial Assistance Application

Financial Assistance Application

Completion of this Financial Assistance Application will allow us to determine if Logan Health is able to consider reduced payments based on financial need. This form is secure and encrypted to protect your privacy.

Review Logan Health's Financial Assistance Policy

Review Logan Health's Privacy Practices

You also may download, print, and mail your Financial Assistance Application

Customer Service and Statement Questions

(406) 756-4408

(844) 349-7900 (toll-free in the U.S.)

(844) 349-7900 (Canada)

Financial Advisors

(406) 752-1767

File Attachments

Please attach the following information: 1.Three months of recent paystubs 2. Most recent tax information 3. SSI award letter(s) 4. SNAP or WIC award letter 5. Disability award letter 6. Last 3 bank statements Your most recent tax return is the best source to document your income. Any attachments to returns of schedules must be included. Please only attach documents as PDF, JPG, or PNG format.

Drag and drop files here or

Patient Information

All fields are required. If a question does not apply to you, enter N/A in the box provided.

Name*

Social Security Number*

Date of Birth*

Address*

City*

State*

Zip Code*

Home Phone*

Work Phone*

Cell Phone*

Email*

Employer*

Position*

Date of Employment*

Insurance*

Policy Number*

Spouse/Significant Other Information

Spouse/Significant Other Name*

Spouse Social Security Number*

Spouse Date of Birth*

Address (if different from patient)*

City (if different from patient)*

State (if different from patient)*

Zip Code (if different from patient)*

Spouse Employer*

Spouse Position*

Spouse Date of Employment*

Spouse Insurance*

Spouse Policy Number*

Household Information

Number of Dependents on Tax Return*

Total Household Size*

Monthly Income: Patient

Patient: Employment/Gross Wages*

Social Security/Pension Income*

Public Assistance*

Unemployment Benefits*

Alimony/Child Support*

Worker’s Compensation*

Any Other Sources of Income*

Describe Other Sources*

Total Monthly Income*

Monthly Income: Spouse/Significant Other

Spouse: Employment/Gross Wages*

Spouse: Social Security/Pension Income*

Spouse: Public Assistance*

Spouse: Unemployment Benefits*

Spouse: Alimony/Child Support*

Spouse: Worker’s Compensation*

Spouse: Any Other Sources of Income*

Spouse: Describe Other Sources*

Spouse: Total Monthly Income*

Monthly Expenses

Rent or House Payment*

Utilities*

Telephone*

Cable*

Groceries*

Prescriptions*

Childcare*

Child Support*

Auto 1: Monthly Payment*

Auto 2: Monthly Payment*

Vehicle Insurance*

Vehicle Maintenance/Gasoline*

Health Insurance*

Life Insurance*

Other Loan Payments*

Payments on Credit Cards*

Payments on Medical Bills*

Total Monthly Expenses*

Additional Information

Unable to provide information on this application?

Please explain:

No income?

Please explain how you meet your expenses:

Annual income increased/decreased from last year?

Please explain:

Any other circumstances?

Please provide additional information about any other circumstances that you think will help us to understand your situation:

Signature*

By entering your full name below, you authorize Logan Health to verify information provided in this financial statement by obtaining a credit report and/or other financial information.

Co-Applicant Signature

By entering your full name below, you authorize Logan Health to verify information provided in this financial statement by obtaining a credit report and/or other financial information.

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