Financial Assistance Application

Completion of this Financial Assistance Application will allow us to determine if Kalispell Regional Healthcare is able to consider reduced payments based on financial need.

This form is secure and encrypted to protect your privacy.

Review Kalispell Regional Healthcare's privacy practices at https://www.krh.org/krmc/patients-and-visitors/patient-rights-and-policies.

You also may print and mail your application: http://www.krh.org/data/content/Financial-Assistance-Application-2017-08.pdf.

Form 8530-020, revised 07/26/17.

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. Most recent paystub(s)
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.

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*

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*

Assets

Cash/Checking/Savings Balance*

Stocks/Bonds/IRA/401K*

Cash Value of Life Insurance*

Auto 1: Year/Make, Model*

Auto 1: Value*

Auto 1: Loan Balance*

Auto 2: Year/Make, Model*

Auto 2: Value*

Auto 2: Loan Balance*

Current Home Value*

Purchase Date*

Purchase Price*

Mortgage Loan Balance*

Other Property (Describe)*

Other Property Value*

Recreational Merchandise*

Other Assets (Describe)*

Other Assets Value*

Total Assets*

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 Kalispell Regional Healthcare to verify information provided in this financial statement by obtaining a credit report and/or other financial information.