Get the free Patient Financial Statement - Lake Regional Health System

Dear Patient: Enclosed is a Financial Assistance application. This application is required to evaluate your account(s) to see if you qualify for financial assistance with your hospital bill(s). For

How to fill out patient financial statement

How to fill out a patient financial statement:

1. Begin by gathering all relevant financial information such as income documents, bank statements, and bills for ongoing medical expenses.
2. Start by filling out personal information such as your name, contact details, and social security number.
3. Provide details about your employment, including your current job, employer's name, and income details.
4. Indicate any additional sources of income such as investments or rental properties.
5. Declare your monthly expenses, including rent/mortgage, utilities, insurance premiums, and transportation costs.
6. List any outstanding medical bills or debts related to healthcare services.
7. Include information about any insurance coverage you may have, such as health insurance or Medicare.
8. Sign and date the form to attest to the accuracy of the information provided.

Who needs a patient financial statement:

1. Individuals who are seeking medical treatment or services and need to provide financial information to healthcare providers.
2. Patients applying for financial assistance or charity care programs at hospitals or healthcare institutions.
3. Individuals applying for government-funded healthcare programs such as Medicaid or the Affordable Care Act subsidies.
4. Patients who want to have a clear overview of their financial situation and expenses related to their healthcare.

For pdfFiller’s FAQs

What is patient financial statement?

Patient financial statement is a form that provides detailed information about a patient's financial status, including income, assets, and debts.

Who is required to file patient financial statement?

Patients or individuals receiving medical services are usually required to file a patient financial statement.

How to fill out patient financial statement?

To fill out a patient financial statement, individuals need to provide information about their income, assets, debts, expenses, and any financial assistance received.

What is the purpose of patient financial statement?

The purpose of a patient financial statement is to assess the patient's ability to pay for medical services and determine any financial assistance or payment plans that may be necessary.

What information must be reported on patient financial statement?

Patient financial statements typically require information on income, assets, debts, expenses, and any financial assistance received.

Can I create an electronic signature for signing my patient financial statement in Gmail?

When you use pdfFiller's add-on for Gmail, you can add or type a signature. You can also draw a signature. pdfFiller lets you eSign your patient financial statement and other documents right from your email. In order to keep signed documents and your own signatures, you need to sign up for an account.

How do I edit patient financial statement straight from my smartphone?

You can do so easily with pdfFiller’s applications for iOS and Android devices, which can be found at the Apple Store and Google Play Store, respectively. Alternatively, you can get the app on our web page: https://edit-pdf-ios-android.pdffiller.com/. Install the application, log in, and start editing patient financial statement right away.

How do I complete patient financial statement on an Android device?

On Android, use the pdfFiller mobile app to finish your patient financial statement. Adding, editing, deleting text, signing, annotating, and more are all available with the app. All you need is a smartphone and internet.