WIXLIB

Breese, ILHSHS St. Joseph’s HospitalFINANCIAL ASSISTANCE APPLICATIONDecatur, ILHSHS St. Mary’s HospitalIMPORTANT: YOU MAY BE ABLE TO RECEIVE FREE OR DISCOUNTED CAREEffingham, ILHSHS St. Anthony’s MemorialHospitalGreenville, ILHSHS Holy Family HospitalHighland, ILHSHS St. Joseph’s HospitalLitchfield, ILHSHS St. Francis HospitalO'Fallon, ILHSHS St. Elizabeth’s HospitalShelbyville, ILHSHS Good Shepherd HospitalSpringfield, ILHSHS St. John’s HospitalChippewa Falls, WIHSHS St. Joseph’s HospitalCompleting this application will help Hospital Sisters Health System determine ifyou can receive free or discounted services or other public programs that can helppay for your health care. Please submit this application to the hospital.IF YOU ARE UNINSURED, A SOCIAL SECURITY NUMBER IS NOT REQUIREDTO QUALIFY FOR FREE OR DISCOUNTED CARE. HOWEVER, a Social SecurityNumber is required for some public programs, including Medicaid. Providinga Social Security Number is not required but will help the hospital determinewhether you qualify for any public programs.Please complete this form and submit it to the hospital in person, by mail, byelectronic mail, or by fax to apply for free or discounted care within 60 daysfollowing the date of discharge or receipt of outpatient care.Patient acknowledges that he or she has made a good faith effort to provide allinformation requested in the application to assist the hospital in determiningwhether the patient is eligible for financial assistance.Eau Claire, WIHSHS Sacred Heart HospitalGreen Bay, WIHSHS St. Mary’s HospitalMedical CenterHSHS St. Vincent HospitalOconto Falls, WIHSHS St. Clare MemorialHospitalSheboygan, WIHSHS St. Nicholas HospitalHSHS Medical GroupPrairie CardiovascularCERTIFICATION STATEMENTI certify that the information in this application is true and correct to the best ofmy knowledge. I will apply for any state, federal or local assistance for which Imay be eligible to help pay for this hospital bill. I understand that the informationprovided in this application may be verified to ensure accuracy. I understand thatif I knowingly provide untrue information in this application, I will be ineligiblefor financial assistance, and financial assistance granted to me may be reversed,and I will be responsible for the payment of the hospital bill.Patient orApplicantSignature:Date:www.hshs.orgSponsored by Hospital SistersMinistries#5515 IL-SBO (R 01/20)Page (1 of 5)

FINANCIAL ASSISTANCE PROGRAMPlease provide copies of the following items that are applicable: Current year W-2 withholding statements Most recent complete federal/state income tax forms including schedules Paycheck/Unemployment check stubs (past 3 months) or written statement of earnings from youremployer (past 3 months). Forms approving or denying Unemployment, Workers Compensation or Assistance from theDepartment of Public Aid Statement of annual benefits from Social Security Complete Checking/Savings account statements (past 3 months) Other: letter explaining your situationYour cooperation with Hospital Sisters Health System (HSHS) is extremely important in determining your eligibility forfinancial assistance. Failure to provide this information will be cause to deny financial assistance.Please return completed application along with required documentation within 30 days of receipt to the following address:Patient Financial ServicesAttention: Financial Assistance ProgramP.O. Box 13427Springfield, IL 62791Telephone Toll Free: 1 (888) 477-4221Email: ILSBO@hshs.org#5515 IL-SBO (R 01/20)Page (2 of 5)HSHS St. Joseph’s Hospital – Breese, ILHSHS St. Mary’s Hospital – Decatur, ILHSHS St. Anthony’s Hospital – Effingham, ILHSHS Holy Family Hospital – Greenville, ILHSHS St. Joseph’s Hospital – Highland, ILHSHS St. Francis Hospital – Litchfield, ILHSHS St. Elizabeth’s Hospital – O'Fallon, ILHSHS Good Shepherd Hospital - Shelbyville, ILHSHS St. John’s Hospital – Springfield, ILHSHS Medical GroupPrairie Cardiovascular Consultants

FINANCIAL ASSISTANCE APPLICATIONAPPLICANT/RESPONSIBLE PARTY INFORMATIONAPPLICANT NAME: (last, first, middle initial)BIRTHDATE:SOCIAL SECURITY NUMBER:PHONE E:ETHNICITY:SEX:PREFERRED LANGUAGE:HOME ADDRESS (City, State, Zip):PREVIOUS ADDRESS (City, State, Zip):HOUSEHOLDMEMBER NAMEMembers offamily unitDATE OF BIRTHRELATIONSHIPTO APPLICANTIf Applicant, SelfLive at homeYesNoSOCIAL SECURITYNUMBERCurrent Patient?YesNo1.2.3.4.5.PRESUMPTIVE ELIGIBLITY CRITERIA:Does any of the information below apply to you? If YES, check all that apply. Please provide documentation/verification if youcheck YES to any of the statements below: Homelessness - shelterDeceased with no estateMental incapacitation with no one to act on patient’s behalfMedicaid eligibility, but not on date of services or for non-coveredserviceIncarceration in penal institution Enrolled in Temporary Assistance for Needy Families (TANF)Enrolled in Illinois Housing Development Authority’s Rental HousingSupport ProgramEnrolled in Wisconsin Department of Health Services HousingAssistance ProgramEnrollment in the following assistance for low-income individuals having eligibility criteria at or below 200% of the federal povertyincome guidelines: Woman, Infants and Children Nutrition Program (WIC)Supplemental Nutrition Assistance Program (SNAP)Low Income Home Energy Assistance Program (LIHEAP) Wisconsin Home Energy Assistance Program (WHEAP)Enrollment in an organized community-based program providingaccess to medical care that assesses and documents limitedlow-income financial status as criteriaReceipt of grant assistance for medical servicesIf you checked YES to any of the above, please stop and send this application and supporting documentation to theappropriate address as shown on page 2.Are you covered or eligible for any health insurance policy, including foreign coverage, Health Insurance Marketplace, Veteran’sbenefits, Medicaid and/or Medicare? If yes, please provide the following information:Policy holder:Insurer:Policy number:Were you covered or eligible under a spouse/partner or former spouse/partner's health insurance policy, foreign coverage policy,Health Insurance Marketplace policy, Veteran's benefits, Medicaid and/or Medicare policy for any or all of your medical services?Former spouse/partner name:Former spouse/partner address:#5515 IL-SBO (R 01/20)Page (3 of 5)Phone number:

EMPLOYMENT 1: HOUSEHOLD MEMBERSALARY (GROSS):EMPLOYER’S NAME:EMPLOYER’S ADDRESS (City, State, Zip):PERIOD: WEEKLY BI-WEEKLYHOW LONG: TWICE A MONTH MONTHLY ANNUALLY(AMOUNT)EMPLOYMENT 2: HOUSEHOLD MEMBEREMPLOYER’S NAME:SALARY (GROSS):PERIOD: WEEKLY BI-WEEKLY(AMOUNT)HOW LONG: TWICE A MONTH MONTHLY ANNUALLYUNEARNED INCOMEPOSITION:YRTYPE OF UNEARNED INCOMEChild support does not need berevealed if you do not wish tohave it considered as a basis forrepaying this obligation.POSITION:YRMOEMPLOYER’S ADDRESS (City, State, Zip):MOHOUSEHOLD MEMBERAMOUNTPERIOD1.2.Please check box if you do notcurrently file taxes.3.4.5.CHILD SUPPORT: NAME OF CHILD (RECEIVING)NAME OF PERSON / PARENT PAYINGAMOUNTPERIOD1.2.HOME:NAME AND ADDRESS OF LANDLORD Rent OwnASSETS/RESOURCESAssets that are countedinclude: cash, checking andsavings accounts, recreationalvehicles, real estate other thanthe home or land you live on, alife insurance policy with acash surrender value, stocksand bonds.TYPE OF ASSETCREDIT/RECURRING ACCOUNTSNAME AND ADDRESSOF CREDITORRENT PMT:DUE DATE:CONTRACT PMT:MORTGAGE PMT:PURCHASE PRICE:DATE PURCHASE:BALANCE DUE:ESTIMATED VALUE:HOUSEHOLD MEMBERWHAT TIONUNPAIDBALANCEMONTHLY PAYMENTAMOUNTPERIOD1.2.3.CHILD SUPPORT EXPENSESHOUSEHOLD MEMBER MAKING PAYMENTCHILD NAME1.2.Are you seeking financial assistance for treatment related to: Workplace injury Accident Crime CancerIf yes, please provide details:#5515 IL-SBO (R 01/20)Page (4 of 5)