Transcription of REQUEST FOR FINANCIAL ASSISTANCE
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REQUEST FOR FINANCIAL ASSISTANCE
REQUEST FOR FINANCIAL ASSISTANCE Palos Community Hospital 12251 S. 80th Avenue Palos Heights, Illinois 60463 (708) 923-4000 YOU MAY BE ABLE TO RECEIVE FREE OR DISCOUNTED CARE: Completing this application will help Palos Community Hospital determine if you can receive free or discounted services or other public programs that can help pay for your healthcare. Please submit this application to the hospital. IF YOU ARE UNINSURED, A SOCIAL SECURITY NUMBER IS NOT REQUIRED TO QUALIFY FOR FREE OR DISCOUNTED CARE. However, a Social Security Number is required for some public programs, including Medicaid. Providing a Social Security Number is not required but will help the hospital determine whether you qualify for any public programs.
Financial Assistance Application Please fill out application completely and to the best of your knowledge PATIENT INFORMATION *If the patient is a minor, list parent(s)/guardian(s) as applicant.
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