The Physicians' Hospital in Anadarko » Financial Assistance Program Application

All information provided will be held confidentially according to our privacy policy
Patient Name*

First

Middle

Last
APPLICANT RESPONSIBILITY – Please read and sign
I certify that the provided information is correct and I hereby authorize The Physicians Hospital in Anadarko and any third party to release to The Physicians Hospital in Anadarko any information required to verify and authenticate this application. I understand that to process this application additional information may be needed and it must be provided by me when requested. I further understand that failure to provide requested information will result in an automatic denial. The Physicians Hospital in Anadarko is authorized to check my credit history and to report to others its credit experience with me. Health Insurance I understand that all health insurance takes precedence over financial assistance. I further understand that all potential insurance claims must be filed and resolved before financial assistance can be applied. I understand that my health insurance company may request additional information to process my claim. I further understand that if I do not provide the requested information and this results in a denial of my claim, my request for financial assistance will be denied and I will be responsible for payment of all charges for rendered services. Third Party Liability: I understand that if this hospitalization is for treatment of an injury, illness, or condition which may have been caused by a third party, for which the third party is or maybe liable for damages, that any claims made by me against the third party and/or any recovery by me from the will take precedence over financial assistance and any financial assistance rendered will be void. I further understand that I will then be responsible for all charges of any covered services.*

Relation to You	Name	Date of Birth	Social Security # (18 years and older only)	Does this person receive Food Stamps?	Does this person receive Medicaid? If yes, what is the ID #?

Financial Assistance Program Application

Financial Assistance Program Application

Step 1 of 2

All information provided will be held confidentially according to our privacy policy

APPLICANT RESPONSIBILITY – Please read and sign

PART A

Applicant Information

PART B

PART C

PART D

PART E

PART F

PART G

PART H

PART I

PART J

PART K