Patient/ Guarantor Account # (s):
Patient Name:
Address:
City:
Contact Phone Number:
Date of Birth:
Spouse/Other Parent Name:
Responsible Party/Parent/Guardian Name:
State:
Zip:
Names and Ages of Dependent Children:
Income Information
Responsible Party’s Employer:
□ Full Time
Hire Date:
Monthly Gross Income: $
Monthly Net (take-home pay): $
Spouse/Other Parent Employer:
Annual Gross Income: $
Full Time
Hire Date:
Monthly Gross Income: $
Monthly net (take-home pay): $
Unemployment: Monthly:$
Child Support: $
Disability\SSI: Monthly: $
Part Time
Annual gross income: $
Date Started:
Pension:$
HRA/HSA Balance: $
Total Household Income: $
□ Part Time
Alimony:$
Other Income:
Total Monthly Gross Income: $
Total Monthly Net (take-home pay):$
Additional Information:
Fixed Monthly Expenses/Assets
Payment To
For
Medical
Amount Owed
$
Monthly Pmt
$
Payment To
Child Support/Alimony
Medical
$
$
Insurance - Auto
$
Housing – Mortgage/Rent
Amount Owed
$
Monthly Pmt
$
Checking $
School Tuition
$
$
Name of Bank
$
Phone/Cable/Internet
$
$
Savings $
$
$
Food/Groceries
N/A
$
Name of Bank
Automobile Make/Model
$
$
Medications
N/A
$
Stocks/Bonds/Retirement Funds: $
Automobile Make/Model
$
$
Utilities
$
$
Other Assets:
Loans - Sum of All
$
$
Gas/Auto
N/A
$
Child Care
$
$
Other Expenses
$
$
Have you applied for state or county medical assistance: □
Yes □
No
For
Other Assets:
Date applied:
If your monthly expenses are more than your income, please explain how you pay your monthly debt:
PROOF OF INCOME: In order to process your application, a copy of all of the following information must accompany your application:

Copy of current bank statements

If under the age of 19, must apply for Medicaid and provide 
Copy proof of all income for household including: Last
date of application. If denied, must provide the denial letter.
two pay stubs, unemployment determination, child support,

Copy of Federal Tax Return (current year) including all
pensions, and or SSI
schedules

Proof of fulltime student status
I hereby acknowledge that the information given to Boys Town National Research Hospital is true and correct to the best of my knowledge. I authorize Boys Town National Research Hospital to
verify any or all information given and to obtain a consumer credit report as deemed necessary.
Patient\Guarantor’s Signature: _________________________________________________
Date: _____________________
I consent to this electronic signature and its use to determine my eligibility for financial assistance from Boys Town National Research Hospital.
To submit this application or additional required documents you can drop off or mail to 1941 S. 42nd St., Ste 380, Omaha NE 68105 or fax them to (402)280-8103.
For any questions, please contact our Financial Counselor at 402-280-8100 or email [email protected]
Last Updated: 12/06/2016