Transcription of FINANCIAL ASSISTANCE PROGRAM TYPE B
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FINANCIAL ASSISTANCE PROGRAM TYPE B
FINANCIAL ASSISTANCE PROGRAM TYPE B8221-071-1 (4/14)2720 Sunset Boulevard, West Columbia, south carolina , 29169 (803) 791-2000I. Applicant Identifying InformationName: _____Date of Birth: _____Social Security #: _____Race: ____Sex: ____Marital Status: _____ Mailing Address or current address: _____ How long at this address? _____City: _____ State: _____ Zip Code: _____ County: _____Address where you live (if different or prior address if less than 4 months at current address): _____City: _____ State: _____ Zip Code: _____ County: _____Telephone numbers: (H)_____(W)_____(C) _____US Citizen: Yes No Permanent Resident: Yes NoII. Third Party Information1. Is there any other insurance? Yes No What type: _____2. Is illness due to an accident?
FINANCIAL ASSISTANCE PROGRAM TYPE B 8221-071-1 (4/14) 2720 Sunset Boulevard, West Columbia, South Carolina, 29169 • (803) 791-2000 I. Applicant – Identifying Information
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