COASTAL MEDICAL ACCESS PROJECT (CMAP)
Please complete the ENTIRE
application and collect ALL
documents needed before coming to
your qualifying appointment.
Appointments are held:
Tuesdays & Thursdays @ 10:00 AM
in the Brunswick Office.
Call (912) 466-8909 EXT. 115,
if you have any questions.
Coastal Medical Access Project • 2605 Parkwood Drive • Brunswick, GA 31520 • 912-466-8909 • www.sghs.org
COASTAL MEDICAL ACCESS PROJECT (CMAP)
Date:
To:
P ROOF OF I NCOME E XPIRES ON:
M EDICAID DENIAL L ETTER E XPIRES ON:
(E STIMATED PROCESSING TIME IS 90 DAYS)
UPDATED PROOF OF INCOME REQUIRED EVERY 6 MONTHS
In order to continue to qualify for clinic services, you must provide updated proof of income. We will be
unable to schedule you for doctor’s appointments, medical tests or order medications until we have received
the requested documents. You will need to prove residency in Brantley, Camden, Charlton, Glynn or
McIntosh Counties. It may also be time for you to update your Financial Assistance with Southeast Georgia
Health Systems, if so please complete an application and return it to our office. This letter will serve as the
only notification you will receive. Please call (912) 466-8909 EXT. 115, if you have any questions.
ALL DOCUMENTATION SHOULD BE PROVIDED AT THE SAME TIME.
Provide ONLY documents that pertain to you below:
Bring household proof of income (This includes income for yourself, your spouse, and your child(ren))
1. Gross Earned Income (Before Deductions)
A. Paycheck stubs for the last 4 weeks.
B. Self Employment Income minus expenses for building, utilities, employee expenses.
C. Statement from your employer stating you are not covered under any insurance plan.
D. 1040 form from current year taxes including schedule C if self –employed OR if you do not file taxes
a signed IRS Form 4506-T (available at CMAP office).
2. Gross Unearned Income (Financial income received in the last 4 weeks from ALL sources)
A. Child Support AND/OR Alimony
B. Social Security: SSDI (Social Security Disability income, Survivor’s Benefits for spouse or minor of a
deceased parent or SSA retirement income). REQUIRED ONCE PER YEAR.
C. Unemployment OR Worker’s Compensation
D. Pensions and Annuities
E. Dividends and interest on Savings, Stocks, Bonds
F. Income from Estates and Trusts
G. Rental Income or Royalties
H. Housing Authority Determination/Review Letter
I. Notarized Statement of Support from other people or organizations. Blank form is attached. (Note:
Financial Assistance from Southeast Georgia Health Systems requires proof of income from the
individual providing financial support).
J. Wage Statement from the Department of Labor is required for ALL individuals who are not employed
OR that complete a Statement of Support.
3. Other Information Required
A. Current Medicaid denial letter from local DFCS office. REQUIRED ONCE PER YEAR.
B. Food Stamps Verification letter.
C. Bring Picture ID
Coastal Medical Access Project • 2605 Parkwood Drive • Brunswick, GA 31520 • 912-466-8909 • www.sghs.org
Cooperative Healthcare Services, Inc.
Coastal Medical Access Project (CMAP)
Patient Information and Authorization Form
Date:____________________
PATIENT INFORMATION
Last Name:____________________________________ First Name:________________________________ MI.: __________
Gender: Male or Female SSN:_________________________ Date of Birth: ______/______/_______
Age: ___________
Race – please check:
Black or African American;
Hispanic or Latino;
American Indian or Alaska Native;
White;
Pacific Island or Hawaiian
Marital Status - please check: S / M / D / W / LP
Primary Language: __________________________________
Household Size - please check: Self / Spouse / Child(ren) #_____ / Grandchild(ren) #_____ / Other: #_____
Mailing Address:______________________________________ City/State:____________________ Zip Code:___________
Home Phone:___________________ Cell Phone: ____________________ Alternate phone number: ____________________
E-mail Address: ________________________________________________________________________________________
Alternate Address:______________________________________ City/State:__________________ Zip Code____________
Employment Status – please circle: Full / Part / Student / Retired / Self / Unemployed / Active duty / Medical Leave / Unknown
Retirement Date: ________________ Patient’s Employer/ (if student, name of school) _______________________________
Employer Address ______________________________________________________
Phone: _______________________
SPOUSE OR PARENT/ GUARDIAN
Relationship to patient: _____________________ Name of spouse or guardian: _____________________________________
Date of Birth ______/_______/_______SSN: __________________________ Phone number: _________________________
Address: _____________________________________________________________________________________________
Employer: ____________________________________________________________________________________________
Employer phone: ___________________________ Employer Address: ____________________________________________
Emergency contact (Relative or Friend not living with you):
Name
Relationship to Patient
Phone Number
Name
Relationship to Patient
Phone Number
Emergency contact will not have access to your medical information unless you list them as a HIPAA contact below.
HIPAA CONTACTS - Name of person you wish to receive any test results, medical or billing information on your behalf:
1. Name: __________________________________
Relationship to you: __________________________________
Date of Birth: _____________________________
Contact Phone #: ____________________________________
2. Name: __________________________________
Relationship to you: __________________________________
Date of Birth: _____________________________
Contact Phone #: ____________________________________
3. Name: __________________________________
Relationship to you: __________________________________
Date of Birth: _____________________________
Contact Phone #: ____________________________________
I acknowledge that this HIPAA authorization remains in effect until I give written notification to discontinue.
________________________________________
__________________________________
_____/_____/_____
Print Name (PARENT OR GUARDIAN IF PATIENT IS UNDER 18)
Signature
Date
AUTHORIZATION AND AGREEMENT FOR TREATMENT
THE UNDERSIGNED HEREBY MAKES THE FOLLOWING ACKNOWLEDGEMENTS AND AGREEMENTS REGARDING THE
TREATMENT TO BE PROVIDED THE PATIENT WHOSE NAME APPEARS ON THIS FORM HEREOF:
CONSENT TO TREATMENT: I understand that medical treatment is necessary for the patient and that such medical care, treatment, and
procedures will be performed by employees of Cooperative Healthcare Services, Inc. I hereby grant my authorization and consent to such
treatment and procedures, and certify that no guarantee or assurance has been made to the results which may be obtained. Treatment
may also be provided by volunteer licensed health care professionals who are immune from professional liability while providing services
as a volunteer. Patients may not contact volunteers at private practices or their private homes, this will lead to termination from the clinic.
RELEASE OF MEDICAL INFORMATION: I hereby authorize Cooperative Healthcare Services, Inc. to release my medical information
in connection with these services for health insurance purposes or to the patient’s personal physician or to a referral physician. I authorize
by my signature below direct payment of all benefits to Cooperative Healthcare Services, Inc. and authorize submission of insurance
forms with this signature on file. I also understand that my records may be shared within Southeast Georgia Health System when
necessary for coordination of my care; and that results of laboratory and/or other diagnostic tests may be mailed directly to me.
PRESCRIPTION ASSISTANCE PROGRAM (MEDBANK): I hereby authorize MedBank of Coastal Georgia to inspect my medical
records whenever necessary to obtain information related to the solicitation of medications on my behalf through patient assistance
programs. Permission is also granted to verify income through the Department of Family & Children Services, Social Security
Administration, Employers, Veterans Administration or any company or organization from which income in received. Permission is also
granted for MedBank of Coastal Georgia to sign forms on my behalf in the solicitation of medication through prescription assistance
programs. I acknowledge that prescription assistance program authorization remains in effect until written notification is given to
discontinue.
AGREEMENT TO PAY FOR SERVICES: CMAP does not pay for any services on your behalf. You must apply for Financial Assistance
through the hospital’s (Southeast Georgia Health System) Business Office. Financial Assistance application may be turned into the CMAP
office for pre-approval along with all required documentation. Patients referred to a specialist outside of the CMAP office are responsible
for any fees incurred.
STUDENT, MANUFACTURING OR COMPANY REPRESENTATIVE OBSERVATION OR ASSISTANCE: I consent that students, including
fellows, residents, Physician Assistants students, Medical Students, interns, Physician Assistants, clinical nursing or technical students,
and manufacturing or company representatives, may observe or assist in the care which will be undertaken at Cooperative Healthcare
Services, Inc.
PRIVACY PRACTICES PATIENT ACKNOWLEDGEMENT: I acknowledge that I have been provided with an opportunity to receive the
Notice of Privacy Practices for Southeast Georgia Health System/Cooperative Healthcare Services, Inc. In reviewing the Notice, I also
acknowledge that I have been provided with an opportunity to ask questions regarding the Notice and its contents.
I HAVE READ THE ABOVE ACKNOWLEDGEMENTS AND AGREEMENTS AND FULLY UNDERSTAND THE SAME.
PATIENT SIGNATURE____________________________________
(PARENT OR GUARDIAN IF PATIENT IS UNDER 18)
DATE:___________________
_____________________________________________
Print Name (PARENT OR GUARDIAN IF PATIENT IS UNDER 18)
TELEPHONE TREATMENT PERMISSION GRANTED BY: _________________________________________________
WITNESS: ____________________
nd
2 WITNESS: ______________________________
(Required for Telephone Treatment Consent)
Georgia Department Of Public Health
Georgia Volunteer Health Care Program (GVHCP)
Financial Eligibility Form
Clinic/Program/Provider:
_____________Coastal Medical Access Project (CMAP)_____________________
SECTION I – PATIENT DEMOGRAPHIC INFORMATION
Patient Name:
___________________________________________________________________________________________________
(Last Name)
(First Name)
(Middle Initial)
Address:
____________________________________________________________________________________________________
(Street)
(City/State)
(Zip Code)
(County)
Telephone/Contact number: __________________ Name of contact if other than yourself: ________________________
Date of Birth: _________________
Race:
White
Black
Sex:
Male
Female
Asian /Pacific Islander
Ethnicity:
Hispanic
Non-Hispanic
American Indian/Alaskan Native
SECTION II - INSURANCE INFORMATION/FINANCIAL ELIGIBILITY
Do you have insurance that covers?
Health
Do you currently have Georgia Medicaid?
Yes
I meet one of the following program eligibility categories:
Vision
Dental
No Insurance
No
Uninsured
Underinsured
Your income must be at or below 200% of the Federal Poverty Level to be eligible to receive services under the GVHCP.
Please provide gross family earned and unearned monthly income: $________________ and your family size ____________.
SECTION III – LEGAL ACKNOWLEDGEMENTS
I understand that I am being referred to a volunteer health care provider who will provide care to me or to someone for whom I
are legally responsible. My participation in this referral process is voluntary. The care I receive from the volunteer health care
professional will be provided at no charge. I understand that the Volunteer is acting as an employee of the State of Georgia by
treating me pursuant to the “Georgia Volunteer Health Care Program.” I acknowledge that the exclusive remedy for any injury
or damage suffered as a result of any act or omission of a health care provider acting within the scope of duties pursuant to that
Program is a lawsuit under the State Tort Claims Act, O.C.G.A. § 50-21-20 et seq., and that a remedy for injury or damage
suffered as a result of any act or omission of a health care provider acting outside the scope of those duties shall be as provided
for under general tort or other applicable law.
The information I have provided regarding my eligibility, including income information, is true and complete to the best
of my knowledge. I understand that any failure to update this information to the Department upon change in my
financial or health insurance status may disqualify me from receiving health or dental care under the GVHCP. I further
understand that making false statements or representations on this form may be punishable under O.C.G.A. Section
16-10-20 by a fine of not more than $1,000 or by imprisonment for not less than one or more than five years, or both.
Signature of Patient/Parent or Guardian
Printed Name of Person Signing
Relationship to Minor
(If applicable)
Signature of Eligibility Specialist
Printed Name of Eligibility Specialist
Date
I, ______________________________________ acknowledge that I need to update the
following information every six months. These forms allow you to remain an active patient at
CMAP; allow us to order your medications in a timely fashion; and assist with medical bills from
SGHS:
1. Proof of Income:
a. check stubs for 1 month OR
b. Statement of Support with provider’s proof of income AND a wage statement
from the Department of Labor.
2. Tax Information:
a. Tax Form 1040 for those who file taxes OR
b.
Form 4506-T for those who do not file taxes
3. Medicaid Denial Letter (needed once per year); if you receive food stamps, please check
the box that allows you to file for Medicaid each time you have a food stamps review.
4. Financial Assistance (Indigent) application from Southeast Georgia Health System
(SGHS).
We can no longer provide you with samples if your paperwork is out of date. We will be happy to
give you a prescription to be filled at a local pharmacy at your cost.
Please notify CMAP when you receive medication at your home. This allows CMAP to re-order
your medication in a timely manner.
Please give us 24 hours notice if you need to cancel an appointment. Three (3) no-shows in a
12 month period will result in a suspension for 90 days.
Please have your pharmacy fax refill request to 912-466-8995; allow three (3) business days for
your refill request to be completed.
____________________________ ________
_______________________ _______
Signature of Patient
Signature of Witness
Date
Date
NOTARIZED STATEMENT OF SUPPORT
 I provide food and/or shelter to ________________________ in the amount of __________
(Name of Applicant)
OR
 I, _____________________________________ contribute the amount of $_____________
(Name of Provider)
each month to assist ________________________________ with his/her financial obligations.
(Name of Applicant)
PROVIDER:
_______________________________ ____________________________ _____________
Print
Signature
Date
APPLICANT:
_______________________________ ____________________________ _____________
Print
Signature
Date
Please note a dollar amount must be included; zero is not acceptable.
Financial Assistance with Southeast Georgia Health Systems requires proof of income
from the individual providing financial support.
State of Georgia
County of __________________________
Sworn to and subscribed before me this _______ day of _____________________, 20______
Who proved to me on the basis of satisfactory evidence to be the person(s) who appeared
before me.
_____ Personally Known or _____ Proved Identification
_________________________________
Notary Public Signature
Seal/Stamp
________________________
Date Commission Expires
PATIENT MEDICAL HISTORY FORM
Today’s Date: _________________
Full Name: ______________________________________ Date of Birth: ______________ Age: _________
Doctors seen in the last 3 years: _____________________________________________________________
________________________________________________________________________________________
Current health problems or symptoms: _________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Medications: _____________________________________________________________________________
________________________________________________________________________________________
PAST MEDICAL HISTORY
Please check all items and give approximate date if illness was in the past.
NO
YES
NOW
YES
PAST
(DATE)
NO
CARDIOVASCULAR
PULMONARY
High Blood Pressure
Heart Murmur
Abnormal Rhythm
Heart Attack
Rheumatic Fever
Angina
Emphysema
Bronchitis, Chronic
Asthma
Tuberculosis
Pneumonia
Other:
GASTROINTESTINAL
Gallstones
Ulcers
Cirrhosis or Hepatitis
Colon or Bowel Problem
UROLOGIC
Kidney Stones
Kidney/Bladder Infections
Prostate Problem (men)
Other
OTHER
WOMEN
Stroke
Migraine
Psychiatric Illness
Seizure
Anemia
Diabetes
Menstrual Problems
Breast Disease
Breast Cancer
Ovarian Cyst
Age Period Started: ________
Age Period Stopped:
________
Number of Pregnancies: _____
Children: _______________
Miscarriages: ____________
Pap Smear:
_______________
Thyroid Disease
Gout
Blood Clot (Phlebitis)
Arthritis
YES
NOW
YES
PAST
(DATE)
Glaucoma
Depression
Cancer – Type:
Skin Disease – Type:
Page 1 of 2
Rev. 9/10/14
LIST ALL SURGERIES WITH DATES
SOCIAL HISTORY:
DO YOU?
ARE YOU ALLERGIC TO ANY MEDICATIONS/FOODS
NO
YES
IN PAST
Exercise
How Often: ________________
Drink Caffeine
Amount/Day: _______________
Date Quit: _________________
Smoke/Chew Tobacco
Amount/Day: _________________
Date Quit: _________________
Drink any alcohol/beer
Amount/Day: _______________
Date Quit: _________________
FAMILY HISTORY
Check condition and enter the relationship
NO
YES
RELATIONSHIP
NONE
YES
DATE
NONE
YES
DATE
Heart Disease
High Blood Pressure
Diabetes
Stroke
Alcoholism
Liver Disease
Cancer of Colon
Cancer of Breast
Cancer of Ovaries
Cancer of Prostrate
Mental Illness
Suicide
X-RAYS/SCREENINGS/CTs/MRIs
When was last:
Mammogram
Chest X-Ray
Colon X-Ray
Colonoscopy
Other:
IMMUNIZATIONS
Influenza Vaccine
Pneumonia Vaccine
Tetanus
Hepatitis
Other:
Have you ever been tested for HIV/AIDS?
NO
YES
DATE:__________________
Have you ever been treated for HIV/AIDS?
NO
YES
DATE:__________________
Page 2 of 2
Rev. 9/10/14
SOUTHEAST GEORGIA HEALTH SYSTEM
APPLICATION FOR FINANCIAL ASSISTANCE
1. Applicant / Patient Information:
Name: _______________________________________________Home Phone: _________________________
Address: _____________________________________________Date of Birth: ___________________________
City, State, Zip: _______________________________________Soc Security #: _______ - _____ - _______
County: ____________________________________________Do you have Health Insurance
Have you previously qualified for assistance from other health care providers?
Yes
Marital Status:
Single
Married
Divorced
Legally Separated
Insurance Information: ________________________________
Yes
No
No
Attach a copy of the insurance card
2. Co-Applicant / Spouse / Guarantor Information:
Name:__________________________________________________
Relationship to Patient:
Spouse
Parent
Other
Social Security Number: _______ - _____ - _______
Marital Status:
Single
Married
Separated
Divorced
Guarantor’s Date of Birth: _____________________
Home Phone Number: _______________ Employer’s Name: __________________________ Work Phone: ___________________
3. Dependents / Household Members:
(List the names of all members in your household and family and their relationship to you. Please check the box ( ) if you claim him/her on
tax return form). If you list any children on your application that are not biological or stepchildren, you must provide legal
documentation to this effect.
Full Name
Relationship to Patient
Date of Birth
/
/
/
/
/
/
/
/
/
/
Social Security #
4. Employer Information:
Patient’s Employer:
Employed
Homemaker
Unemployed
Disabled
Retired
Spouse’s / Other Household Member’s Employer:
Employed
Homemaker
Retired
Unemployed
Disabled
Employer’s Name: ________________________________
Employer’s Name: ________________________________
Address: ________________________________________
Address: ________________________________________
Job Title: _______________________________________
Job Title: _______________________________________
Length of Employment: ____________________________
Length of Employment: ____________________________
Weekly hours worked: _______ Annual Income: $______
How are you paid?  Weekly  Bi-Weekly  Month  Other
Weekly hours worked: _______ Annual Income: $______
How are you paid?  Weekly  Bi-Weekly  Month  Other
1
Household Income: Defined as income of all individuals who live together and typically purchase and prepare meals
together. List the amount of your monthly income from all sources. If a family member or someone other than a family member
provides more than 50 percent support for living expenses, please provide monthly income for the supporting individual.
Please provide a copy of documentation to support each income and asset source listed.
5. Monthly Household Income Information: Give monthly income for yourself and other household members.
Patient
Spouse
Wages (including tips)
Proof Needed
Pay stubs and most recent Federal
Income Tax 1040
Income Statement, Schedule C/E from
Federal Taxes
Benefit Statement for all who receive
Business Income
Social Security benefits (SSA/SSI) / Disability
Retirement / pension benefits
Public Assistance benefits (food stamps)
Veterans benefits
Unemployment benefits
Rental Property Income (Does anyone pay you rent?)
Benefit Statement
Budget Worksheet
Benefit Statement
Benefit Statement
Income Statement, Schedule C/E from
Federal Taxes
Statement
Workers’ Compensation
Alimony or Child Support Payments Received
Other Income: ________________________
Total Monthly Gross Income:
Court order stating amount
$
Unemployment: If you do not have income, please explain how you take care of your monthly living expenses. You
may be asked to furnish a letter from the Department of Labor regarding your unemployment status.
6.
Monthly Expenses: Give information about the bills you pay every month.
Monthly Expenses
Rent/Mortgage Payment
Utilities
Food
Cable
Auto Loan(s)
Auto Insurance
Loans
Total Monthly Expenses:
Monthly Payment
Monthly Expenses
Credit Cards (minimum payment)
Child Support
Spousal Support/Alimony
Child Care
Liens / Wage Garnishments
Medical Bills
Other:
Monthly Payment
$
Total Monthly Income (Section 5)
Total Monthly Expenses (Section 6)
Total Monthly Income – Total Monthly Expenses
$
7. Bank Account Balances: Attach copies of your account statements.
Patient
Spouse
Financial Institution
Checking Account Balance
Savings Account Balance
Stocks, bonds, CD or money market Balance
Other accounts: ___________________________
Total Bank Accounts:
$
2
8. Assets / Property: Include all property and assets that you own, including all recreation vehicles, etc.
Type
Detail
Residence
Vehicle #1
Vehicle #2
Vehicle #3
Land
Rental Property
Business
Other
A. Total EstimatedValue
Estimated
Value (A)
Unpaid
Balance (B)
Type/Year/Make
Type/Year/Make
Type/Year/Make
Number of Acres
B. Total Unpaid Balance
Estimated Value (A) – Loan Balance (B)
$
9. Additional Information: Provide information regarding the medical service in which you need assistance.
I am applying for a scheduled service.
Yes
No
If yes:
Who referred you for the service (doctor/other): _______________________
Type of medical service: __________________________________________
Date of scheduled medical service: __________________________________--or-Doctor’s requested timeframe: ______________________________________
I am applying because I have existing bills that I cannot pay.
Yes
No
Please list the account number(s): _______________________________________________________________
Medicaid Application Status:
Have you applied for Georgia Medicaid?
Yes-Awaiting Approval
Yes-Not Eligible
No (if you indicated no, please check all that apply to you below)
I am currently pregnant
I am the parent or relative caretaker of dependent children under 19 years of age
I am 65 years of age or older
I am blind
Myself, or someone within my household, has a disability
Note: If you have applied for Medicaid and have not received a final determination, please contact your caseworker.
3
Please Read the Following Before Signing and Dating the Application
Please be advised that your signature indicates that you have agreed to attach all income verification. In addition to the items
requested by this application, you may attach bank statements, copies of social security checks (or letters). If there is no income,
please verify how expenses are being met. It is important to explain a lack of income completely so that full consideration of
your application can be made. If the guarantor/patient of the spouse is self-employed, please attach the last 2-3 months of bank
statements. Additional information may be requested by the financial advocate. All documentation must be attached for full
consideration. Incomplete applications will be returned. Representatives are not required to follow up with applicants who
submitted incomplete applications.
Certification
1.
2.
3.
4.
I, the undersigned, certify that the completed information in this document is true and accurate to the best of my
knowledge.
I will apply for any and all assistance that may be available to help pay this bill.
I understand the information submitted is subject to verification; therefore, I grant the permission and authorize
any bank, insurance company, real estate company, financial institution and credit grantors of any kind to
disclose to SOUTHEAST GEORGIA HEALTH SYSTEM all pertinent information regarding past and present
accounts.
I understand that financial assistance will not be granted if complete and accurate information and supporting
documentation are not provided.
I, ___________________ , give permission to Southeast Georgia Health System to share information contained in
this application and supporting documentation with Cooperative Healthcare Services, Inc.
_______________________________________________________
Signature Patient/Guardian
_______________________________
Date
_______________________________________________________
Signature Spouse
_______________________________
Date
Please return completed application and required documentation to:
Southeast Georgia Health System
Attention: Financial Assistance Department
P. O. Box 1518
Brunswick, Georgia 31521
(912) 466-5000
4
SOUTHEAST GEORGIA HEALTH SYSTEM
Supporting Documentation Requirements
Financial Assistance may only be granted based on the receipt of a completed and signed Financial Assistance
application along with the following documentation requirements: (Please Provide Copies Only)
Note: Financial Assistance is based on a two-part test that involves income and net assets. Individuals with net assets in
excess of $10,000 or families with net assets in excess of $25,000 are not eligible for scheduled financial assistance.
Step 1) Verification of Identification (1 document required) – Copy Only
Georgia Driver’s
License
Georgia State ID Card
College/Student ID
Permanent Resident
Card (Green Card)
Step 2) Verification of Residency – For applicants that do not have a current driver’s license or state ID (1 document required)
– Copy Only
Utility Bill with
Voter Registration
Mortgage Lease or
Complete Name and
Property Tax Bill
Card
Statement
Address
Step 3) Proof of Income – Provide documentation to support each income amount listed on application: Copies Only.
Note: We may require more than one document to confirm income.
W-2 from Most
Employer Notarized
Pay Stubs: Lat Month:
Current Tax Return /
Recent Tax Filing
Letter Confirming
(4-Weekly, 2-Biweekly,
W-2
(If no taxes are
Monthly Income
1-Monthly)
available
Amount
Social Security –
Alimony and /or Child
Unemployment
Social Security SSDI)
Bank Statement
Support
Benefits 1099 Award
Award Letter
Showing Auto
Documentation
Letter
Deposit
Notarized Court
*Support Notarized
Food Stamps Award
Cash Assistance Award
Letter Stating
Letter Stating
Letter
Letter
Income
Assistance to Patient
Self Employed – Most Recent Tax Return – All Pages: (Last Year) Including but not
Self Employed –
limited to Self Employment Earnings (Schedule C from Tax Return), Schedule E from
Income Statement
Taxes (Rental Schedule)
Step 4) Verification of Assets – Provide documentation to support each asset amount listed on application: Copies Only.
Note: We may require more than one document to confirm assets.
Checking Account
Savings Account
Mortgage
Stocks Statement
Last 2 months
Last 2 months
Statement
Certificate of Deposit
Money Market
Reverse Mortgage
Bonds Statement
Statement (CD)
Statement
Benefit Statement
Vehicle - Proof of
Other
Ownership
*If someone other than your spouse is providing you more than 50 percent support for living expenses, please provide the
above documentation for the supporting individual.
5