Compassionate Care Program Application

Dear Patient:
Thank you for inquiring about our Compassionate Care Program.

After receiving your application we will contact you to send us the following:

• Current income tax return.
• Most recent pay stub.
• Information (and proof) of all other income.
• DSHS Denail (if you've been denied DSHS assistance)

Your application will be reviewed and a final determination made within 14 days. You will receive written notification of this decision. If you have any questions or if I may assist you with this process, please call me at (509) 663-8711, extension 5093.

Sincerely,
Jim Markel
Compassionate Care Program Coordinator

Medical Center Account Number:

General Information

	Patient First Name:
	Patient Last Name:
	Age:
	Date of Birth:
	Present Address:
	City:
	State:
	Zip:
	Email Address:
	Phone Number:
	Marital Status :	Married   Widowed Single   Divorced Seperated
	Name of Spouse:
	Spouse's Age:
	Spouse's Date of Birth:

Dependents that I Support

Dependant Information Person #1
	Name:
	Age:
	Date of Birth:
	Relationship:

Dependant Information Person #2
	Name:
	Age:
	Date of Birth:
	Relationship:

Dependant Information Person #3
	Name:
	Age:
	Date of Birth:
	Relationship:

Dependant Information Person #4
	Name:
	Age:
	Date of Birth:
	Relationship:

Dependant Insurance Information
	Medical Insurance:
	Address:
	Group Number:
	Plan Number:
	Effective Date:
	Who is covered?
	Have you applied for state or other aid?
	If so, when?

Employment

Patient Employment Information
	Name of Employer:
	Position:
	Employer's Address:
	Hours per Week:
	Length of Employment:
	Rate of Pay: (before deductions)
	If Unemployed, when did you last work?

Spouse Employment Information
	Name of Employer:
	Position:
	Employer's Address:
	Hours per Week:
	Length of Employment:
	Rate of Pay: (before deductions)

Additional Employment Information
	Please provide any other current employment information including employer's name and rate of pay.

Other Income

		Applicant	Spouse
	Retirement:	per month	per month
	- Social Security:	per month	per month
	- Veteran's Pension:	per month	per month
	- Railroad Retirement:	per month	per month
	- Military Service Allotment:	per month	per month
	Food Stamps:	per month	per month
	Unemployment Comp.:	per month	per month
	Workman's Comp.:	per month	per month
	Union Benefits:	per month	per month
	Insurance:	per month	per month
	Friend/Relative:	per month	per month
	Alimony/Child Support:	per month	per month
	Property Income:	per month	per month
	Other	per month	per month

Assets

Cash On Hand - Checking/Savings Accounts
	Bank Name:
	Account #:
	Estimated Value:

Personal Property/Other - Vehicles, Etc.
	Desrcibe:
	Estimated Value:

Other Medical Expense Obligations

	Provider Name	Current Balance

Monthly Obligations

		Monthly Payment	Unpaid Balance
	Mortgage/Rent :
	Property Tax (if seperate from mortgage):
	Utilities
	- Electric:
	- Water:
	- Sewer:
	- Garbage:
	Food:
	Cable:
	Credit Cards (list seperately)
	-
	-
	-
	-
	-
	Bank/Credit Union Loans:
	Day Care/Child Support:
	Auto Insurance:
	Health Insurance:
	Life Insurance:
	Entertainment:
	Alcohol/Tobacco:
	Donations/Church/Other:
	Automobile Gas:
	Other Obligations:

Gross income for the previous twlve (12) months: $

Please Read Carefully and Digitally Sign Below

Review your application carefully to ensure you have answered each question. I understand that the information that I submit is subject to verification by the Medical Center and subject to review by federal and/orstate enforcement agencies and that a credit check may be obtained. I certify that the above information is true and correct to the best of my knowledge. Signature of Applicant: Date: