Rainforest Recovery Center Sliding Fee Scale Application

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2 Rainforest Recovery Center Sliding Fee Scale Application Guarantor Name: Guarantor Social Security# Guarantor Date of Birth: Guarantor Street Address: Guarantor Mailing Address: Guarantor Phone Number: Guarantor Current Employer: Spouse Current Employer: Dependents Living in Household: Monthly Income: (Proof of all income must be attached before application will be processed) Family Income: If you have only employment income, a minimum of 3 months current paystubs or W2 s required before application will be processed. Guarantor Wages: Spouse Wages: Parents: (if applicable) Social Security: Pension: PFD: Food Stamps: Unemployment Income: Public Assistance: Corporation Dividends: Other: Total Monthly Income: *Monthly income is converted into annual income Total Annual Income: *Monthly income x 12 months RRC SFS Application Packet 1

3 1) Have you applied for Medicaid for these services? 2) Have you applied for the RRC Sliding Fee Scale program or BRH Charity Care program in the past? A) If so when did you apply and what was the outcome? Assets: Bank Accounts: Checking: Bank Name: Acct # Balance: Checking: Bank Name: Acct # Balance: Savings: Bank Name: Acct # Balance: IRA Bank Name: Acct # Balance: 401K Bank Name: Acct # Balance: FINANCIAL RESPONSIBILITY I certify that the above information is true and accurate to the best of my knowledge. I understand that payment of this bill is my responsibility and that the information provided is for the hospital to see if I will qualify for charity care. I understand any charges that are not covered because of my noncompliance with the agency/insurance requirements will not be considered under this program. My signature below constitutes permission for Bartlett Regional Hospital to verify any information provided including a credit check when applicable. If any information I have given proves to be untrue, I understand the Hospital will require payment in full of this debt. Guarantor signature: Date: FOR HOSPITAL USE ONLY: Date received: Received by: Determination: Determination made by: Reason if Denied: Application Expiration Date: RRC SFS Application Packet 2

4 Rainforest Recovery Center 3250 Hospital Dr. Juneau, Alaska Telephone UNEMPLOYED PERSON SUPPLEMENT (To be completed only if you are unemployed) 1. Are you looking for work? Describe your efforts. 2. When do you expect to be employed? 3. Does someone provide you with housing, food, clothing or cash? If so please a. List their names: b. Housing: c. Food: d. Clothing: e. Cash: 4. If you have no income and are not receiving help from friends or relative, a. Please explain: b. How do you pay rent? c. How do you buy food? d. What do you do for Cash? 5. Have you applied for Unemployment Benefits? Applicant s Signature: Date: RRC SFS Application Packet 3

5 Rainforest Recovery Center 3250 Hospital Dr. Juneau, Alaska Telephone BANK ACCOUNT SUPPLEMENT (To be completed only if you don t have a bank account) If no bank account is declared on your application, please explain the following: 1. How do you pay your rent? 2. Where do you cash your checks? 3. Does your name appear on any checking or savings account? If yes list the name of the bank and type of account If your name appears on someone else s account and you are a signer on that account, we do still require copies of your bank statements before your application can be processed. Applications Signature: Date: RRC SFS Application Packet 4

6 Rainforest Recovery Center Sliding Fee Scale Program 2013 Alaska Poverty Guidelines Number in 100% 75% 50% 25% No Household Write-off Write-off Write-off Write-off Write-off 1 $0-14,350 $14,351-$19,133 $19,134-$23,917 $23,918- $28,700 $28,701 2 $0-$19,380 $19,381-$25,840 $25,841-$32,300 $32,301-$38,760 $38,761 3 $0-$24,410 $24,411-$32,546 $32,547-$40,682 $40,683-$48,820 $48,821 4 $0-$29,440 $29,441-$39,253 $39,254-$49,066 $49,067-$58,880 $58,881 5 $0-$34,470 $34,471-$45,960 $45,961-$57,450 $57,451-$68,940 $68,941 6 $0-$39,500 $39,501-$52,666 $52,667-$65,832 $65,833-$79,000 $79,001 7 $0-$44,530 $44,531-$59,373 $59,374-$74,216 $74,217-$89,060 $89,061 8 $0-$49,560 $49,561-$66,080 $66,081-$82,600 $82,601-$99,120 $99,121 For families/households with more than 8 persons, add $5,030 for each additional person. SOURCE: Federal Register, Publication date January 22, 2013 document number RRC SFS Application Packet 5