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

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.

Drop your files here

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

mm/dd/yyyy

Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Employer

Position

Date of Employment

Insurance

Policy Number

Spouse/Significant Other Information

Spouse/Significant Other Name

Spouse Social Security Number

Spouse Date of Birth

mm/dd/yyyy

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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