Online Application "*" indicates required fields Welcome to your Amberwell Health online financial assistance application! In order to process your application, we need supporting documents to verify your financial situation. Required documents include any of the following that apply to your household: Pay Stubs (last two months) Bank Statements for Checking and Savings Accounts (last two months) Most Recent Tax Return After reviewing your submitted application, we may reach out to assist you with additional programs and insurance options available to you. Please get an electronic copy or pictures of your documents ready before starting your application. If you submit an incomplete application, we will reach out to you for any additional information or documentation needed to process your application. Please select your hospital* Atchison Hiawatha Applicant Name* First Middle Last Applicant Date of Birth*Applicant Address* Street Address City State ZIP / Postal Code Phone Number*Email Including yourself, what is the total number of immediate family members who live in your home?*“Family” includes the applicant, applicant’s spouse, and all of their children under 18 (natural or adoptive).Please enter a number from 1 to 8.Additional Household Member 1 – Name* First Last Additional Household Member 1 – Date of Birth*Additional Household Member 1 – Relationship to Applicant*Additional Household Member 2 – Name* First Last Additional Household Member 2 – Date of Birth*Additional Household Member 2 – Relationship to Applicant*Additional Household Member 3 – Name* First Last Additional Household Member 3 – Date of Birth*Additional Household Member 3 – Relationship to Applicant*Additional Household Member 4 – Name* First Last Additional Household Member 4 – Date of Birth*Additional Household Member 4 – Relationship to Applicant*Additional Household Member 5 – Name* First Last Additional Household Member 5 – Date of Birth*Additional Household Member 5 – Relationship to Applicant*Additional Household Member 6 – Name* First Last Additional Household Member 6 – Date of Birth*Additional Household Member 6 – Relationship to Applicant*Additional Household Member 7 – Name* First Last Additional Household Member 7 – Date of Birth*Additional Household Member 7 – Relationship to Applicant* Household Financial Information Please provide any income that members of your household receive. If none, enter 0. What is the applicant's gross monthly employment income (before taxes)?*What is the applicant's gross monthly income from all other income sources (before taxes)?*What is the applicant's spouse/other gross monthly employment income (before taxes)?*What is the applicant's spouse/other gross monthly income from all other income sources (before taxes)?*Did you file taxes for the prior year? Yes No If there is no household income, please explain how you are being supported: Insurance Information Please provide your health insurance/medical coverage information, if applicable. Insurance Company NameInsurance Member IDInsurance Group NumberSubscriber Name Uploading Documents This section is for attaching the documents we need to fully process your application and verify the information you provided. Please include copies of all of the following that apply to your household. Bank Statements for Checking and Savings Accounts*Please upload your statements from your checking and savings accounts for the past 2 months. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Pay Stubs*Please upload paystubs for all income earners for the past 2 months. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Tax Returns*Please upload your tax returns from last year. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Medical Insurance and/or Medicaid Card – Front & BackPlease attach pictures or copies of the front and back of your medical insurance or Medicaid card effective at the time of service, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. This field is hidden when viewing the formTotal Family Income 3 months prior to the date of service?This field is hidden when viewing the formTotal Family Income 12 months prior to the date of service?This field is hidden when viewing the formFamily AdditionalsThis field is hidden when viewing the formTotal Family SizeThis field is hidden when viewing the formFamily Additional Total 5380This field is hidden when viewing the formYearly Rate 15060This field is hidden when viewing the formTotal 12 Month Income Div by 12This field is hidden when viewing the formCalculated % FPL 12 MonthsSignature of Applicant*I certify that the information in this application is true and correct to the best of my knowledge. I will apply for any state, federal or local assistance for which I may be eligible to help pay my medical expenses. I understand that the information provided may be verified, and I authorize Amberwell Health to contact third parties to verify the accuracy of the information provided in this application. I understand that if I knowingly provide untrue information in this application, I will be ineligible for financial assistance, any financial assistance granted to me may be reversed, and I will be responsible for the payment of the medical bill(s). I grant Amberwell Health permission to contact me using any method provided on this application. Are you ready to submit your application?* No I’m Ready On a scale from 1-5, with 1 being HARD and 5 being EASY, how was your experience applying for Financial Assistance online?Please enter a number from 1 to 5.Great! Please do not close your browser or leave this page until you see the confirmation page.NameThis field is for validation purposes and should be left unchanged.
