Step 1 of 4 25% This is a multi-page application, please have both income and expenses information along with income proof that you can upload. You can also save and continue at another time if you need to, a link can be emailed to you to come back to your appliaction.Patient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Social Security Number(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Responsible Party First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Social Security Number Responsible Party's SS number.Marital Status Single Married Separated Do You Have Insurance? Yes No What insurance do you have?Occupation Rate of PayPay by Hour, Month, YearPer HourPer MonthYearly Additional Family MembersNumber of Additional Family MembersChoose123456Family Member 1Family Member 1 Name First Last Family Member 1 Birth Date MM slash DD slash YYYY Family Member 1 Relationship to Patient Family Member 1 Social Security Number Family Member 2Family Member 2 Name First Last Family Member 2 Birth Date MM slash DD slash YYYY Family Member 2 Relationship to Patient Family Member 2 Social Security Number Family Member 3Family Member 3 Name First Last Family Member 3 Birth Date MM slash DD slash YYYY Family Member 3 Relationship to Patient Family Member 3 Social Security Number Family Member 4Family Member 4 Name First Last Family Member 4 Birth Date MM slash DD slash YYYY Family Member 4 Relationship to Patient Family Member 4 Social Security Number Family Member 5Family Member 5 Name First Last Family Member 5 Relationship to Patient Family Member 5 Birth Date MM slash DD slash YYYY Family Member 5 Social Security Number Family Member 6Family Member 6 Name First Last Family Member 6 Relationship to Patient Family Member 6 Birth Date MM slash DD slash YYYY Family Member 6 Social Security Number Monthly Income(List all income for yourself, spouse and other dependents, from any of the following:)WagesSelf EmploymentUnemploymentAlimony / Child SupportPensionsPublic AssistanceWorkers CompRental Prop IncomeDividends & InterestLottery WinningsOthersTotal Monthly Income Proof of income is required. Please provide the following:Self Employment DocumentsMax. file size: 300 MB.If self-employed, three month Profit and Loss statement and most recent tax returnIncome Tax FormsMax. file size: 300 MB.Income Tax Forms, valid January Through April onlyEmployment DocumentsMax. file size: 300 MB.4 most recent pay stubs, including year-to-date totals from all employers.Financial SituationMax. file size: 300 MB.Written explanation of current financial situation - Notarized.Other DocumentsMax. file size: 300 MB.Denial notice from the Department of Human Services or other proof of your income.Consent I agree that the information is correct.I affirm that the given information, including income, is true and correct to the best of my knowledge. I understand that the information I submit concerning my annual income and family size is subject to verification by The Aryana Health Care Foundation. I also understand that if the information which I submit is determined to be false, such determination will result in a denial of providing services as Free Care, and that I will be liable for charges for services provided.For patients completing this application to justify lower monthly payments, please include the following information related to expenses.Monthly Expenses: List all monthly expenses that apply.Housing (Mortgage/Rent)Property Taxes:Credit Cards/Loans:Auto Loans:Phone:Electricity:Water / SewerChild Care:Fuel:Health Insurance:Insurance:Food:Other:Total Expenses
