Financial Assistance Program Application

Application for Free and Reduced-Charge Services under the ICTF Program

List members of household, birth date, relationship to patient and income from each source; state whether income is per week month or year.

(Note to applicant: You do not have to report income for a person in the household who is not legally responsible for the patient’s medical bills and is not counted in the family size. For example, if you have a brother or sister who lives with you, that person is not responsible for paying your medical bills and would not have to be counted or report income.)

For Hospital Staff Use:

(Average monthly income for last year or past 3 months, whichever is more favorable.)