Financial Assistance Program

	The Financial Assistance Program is designed to help you with the balance on your Abbeville 
	General Bill.  This program is available to all Abbeville General Patients.

	If you are interested in applying for financial assistance, please complete all sections of the 
	attached application form and send the documents that are applicable as listed on the 
	following page.  You may also come into the office and sign up or provide application along 
	with your documents.  

	After I receive the documents, your application will be reviewed.  The determination will be 
	made based on your level of income.  I will mail you a letter with the application decision.

	Please contact me directly if you have any questions or concerns.

	** Please let us know if you are interested in Medicaid, as you will need an appointment.
	    If you have insurance, please let us know.

	Return application and supporting documents to:

	Abbeville General Hospital
                       Attn;Shekera Tardy, Patient Financial Services
	Attn: Patient Financial Services
	P. O. Box 580
	118 N. Hospital Drive
	Abbeville, LA  70510

	Application for Financial Assistance
	Page 1	Patient Information

	Name:	_________________________________________	Birthdate:	____/____/________

	Address:	_________________________________________	Social Security #:	______‑____‑________

	_________________________________________	Home Phone:	(______)  ______‑________

	City/State/Zip:	_________________________________________	Cell Phone:	(______)  ______‑________

	Marital Status:	Single   Married   Divorced
	Circle Selection

	Employer:	_________________________________________	Phone:	(______)  ______‑________
	Spouse Employer:	_________________________________________	Phone:	(______)  ______‑________

	Guarantor Information

	Guarantor Same As Patient:  Yes  No	Circle Selection	Relationship to Patient:	______________________

	Name:	_________________________________________

	Address:	_________________________________________	Phone:	(______)  ______‑________

	_________________________________________	Marital Status:	Single   Married   Divorced
	Circle Selection
	City/State/Zip:	_________________________________________

	Employer:	_________________________________________	Phone:	(______)  ______‑________

	Family Size:
	Members Of Household

	Name	Relationship	Birthdate	Monthly Income

	_______________________________________________	_______________	____/____/_______	____,______.____

	_______________________________________________	_______________	____/____/_______	____,______.____

	_______________________________________________	_______________	____/____/_______	____,______.____

	_______________________________________________	_______________	____/____/_______	____,______.____

	_______________________________________________	_______________	____/____/_______	____,______.____

	_______________________________________________	_______________	____/____/_______	____,______.____

	_______________________________________________	_______________	____/____/_______	____,______.____

	_______________________________________________	_______________	____/____/_______	____,______.____

	( Application Continues to Page 2 )

	

                            Application for Financial Assistance
	Page 2	Required Documents

	Federal Tax Return (1040) For The Last Calendar Year

	Paycheck Stubs For The Most Recent Three (3) Months

	Social Security Benefits Letter

	Disability Benefits Letter

	Unemployment Benefits Letter

	Workman's Compensation Letter

	SNAP (Food Stamps) Letter

	Child Support Letter

	Alimony Letter

	Proof of Identification

	If You Have No Income Of Your Own, A Letter From Person Providing For Your Needs For Past Year To Present

	          ( Must Provide Name, Address, And Phone Number On Letter )

	

	Have You Applied For Medicaid To Cover your Medical Expenses:  Yes  No    	Circle Selection

	Would You Consider Applying For Medicaid:   Yes  No	Circle Selection

	If You Have Been Denied Medicaid Or Other Public Assistance, What Reason Was Given?

	_______________________________________________________________________________________________

	_______________________________________________________________________________________________

I am applying for Financial Assistance for health care services rendered at Abbeville General.  I certify that the data 
	given is complete and accurate to the best of my knowledge.

	Signature:  ___________________________________	Date:  ____/____/________

	* * *  FOR OFFICE USE ONLY  * * *
	Income for past three months times four:	____,______.____	Family size:

	Approved	Reason Denied:  _____________________________________________________________________

	Denied	_____________________________________________________________________________________

	Circle Selection

	

 

	I,	, the responsible party for
	(Guarantor)	(Patient)
	am providing proof of the following iinformation to Abbeville General:

	1. My family income for the last three months times four (4) was 
	$

	2.Family size as determined by dependents defined by the internal revenue code is

	I understand that this declaration is being provided to the Louisiana Department of Health and 
	hospitals in connection with services provided by Abbeville General.  I understand that if I 
	qualify for this program, only hospital billings will be paid and that I will still be responsible for  
	any billings related to this service from any physician, radiologist, pathology service, etc. 

	Under the penalties of perjury, I declare that I have examined this declaration, as to the best of 
	my knowledge and belief it is true, correct and complete.

	Signature:  ______________________________________