Online Application "*" indicates required fields CompanyThis field is for validation purposes and should be left unchanged.Welcome to your Logansport Memorial Hospital online financial assistance application! In order to process your application, we need supporting documents to verify your financial situation. Required documents include any of the following that apply to your household: Required Docs Paycheck Stubs (3 months prior to date of service) Social Security/Disability Benefit Letter(s) Pension Verification Letter Last Year’s Tax Return & W-2’s Government Cash Assistance Benefits Letter Alimony/Child Support Statement Bank Statements both Checking and Savings (3month prior to date of service) Unemployment Statement U.S. Permanent Resident Card After reviewing your submitted application, we may reach out to assist you with additional program and insurance options available to you or request additional documentation. Please get an electronic copy or pictures of your documents ready before starting your application. If you submit an incomplete application, we will reach out to you for any additional information or documentation needed to process your application. Do you have your proof of income documents ready?* Yes No I will mail in or drop off my proof of income documents at Logansport Memorial Hospital in the next 10 days.*The address to send or drop off your documents to is: 1101 Michigan Avenue, Logansport, IN 46947. Yes Household Information Including yourself, what is the total number of people living in your household?*Please enter a number from 1 to 10.Patient InformationName* First Last Date of Birth*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Is the patient also the responsible party for the accounts?* Yes No If no, who is the Responsible Party/Applicant?* First Last Household Income InformationDo you or any members of your household receive income from any sources?*Income sources = Social Security/Disability income, Pension income, Unemployment, VA benefits, Worker Compensation, Self- employment, Rentals, Alimony, Child Support, 401/IRA withdraws and other sources of income. Yes No What is the total family gross income before taxes?*If no, please explain how you are being supported financially.* Insurance InformationAt your service date did you have any plan, group or insurance that reimburses medical expenses?* Yes No Insurance Company NameInsurance Group NumberInsurance Member IDWere you an active Medicaid recipient at the time of your hospital service, or on Disability?* Yes No Please provide each date of service you are responsible for that should be considered on this application.Date of ServiceDo you have another date of service to add? Yes No Date of ServiceDo you have another date of service to add? Yes No Date of ServiceDo you have another date of service to add? Yes No Date of ServiceDo you have another date of service to add? Yes No Date of Service Uploading Documents This section is for attaching the documents we need to fully process your application and verify the information you provided.Proof of IncomePlease provide proof of income: A copy of your W-2, or payroll stub. Drop files here or Select files Max. file size: 50 MB, Max. files: 10. Medical Insurance and/or Medicaid Card – Front & BackPlease attach pictures or copies of the front and back of your medical insurance or Medicaid card effective at the time of service, if applicable. Drop files here or Select files Max. file size: 50 MB, Max. files: 10. This field is hidden when viewing the formNumberThis field is hidden when viewing the formFamily AdditionalsThis field is hidden when viewing the formTotal Family SizeThis field is hidden when viewing the formFamily Additional Total 5500This field is hidden when viewing the formYearly Rate 15650This field is hidden when viewing the formTotal 12 Month Income Div by 12This field is hidden when viewing the formCalculated % FPL 12 MonthsSignature*By my signature below, I certify that everything I have stated on this application and on my attachments is true. If incorrect information is provided at the time of application, this determination may be rescinded upon review. Are You Ready to Submit Your Application?* No I’m Ready On a scale from 1-5, with 1 being HARD and 5 being EASY, how was your experience applying for Financial Assistance online?Please enter a number from 1 to 5.This field is hidden when viewing the formStatusNewIn ProgressClosedGreat! 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