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IREDELL COUNTY HOME HEALTH AGENCY 4345
REQUEST FOR PATIENT FINANCIAL INFORMATION
(Information Furnished will be Kept Strictly Confidential)
The Iredell County Home Health Agency follows the practice of providing Home Health
Care Services to the residents of the communities served by the Agency at fees that
are based on their ability to pay. To insure that the funds available to finance
fee adjustments are used equitably throughout the Agency service area and that the
fee established for the individual is fair, each person who requests services and
feels unable to pay the full fee is required to provide certain information pertaining
to their financial situation.
Please furnish the following data so that we will be able to determine a fee for
the services you will be receiving. Keep in mind that incomplete or inaccurate
disclosure by you will result in you being obligated for the full charge for ser-
vices rendered.
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NAME OF PATIENT
ADDRESS OF PATIENT
NUMBER IN FAMILY
CURRENT INCOME INFORMATION
Annual
Amount
Source
Gross Earned Income -Patient
and spouse ................ 5
_• Other Income:
Social Security... ....
Pension (R.R., VA, Other),
Annuity .........................
Insurance or Disability
Payments ......................
Income From Rents ...............
Interest and Dividends..........
AllOther .......................
TOTAL
UNUSUAL EXPENSES OR ITEMS (SPECIFY):
I AUTHORIZE YOU TO OBTAIN SUCH INFORMATION AS YOU MAY REQUIRE TO VERIFY STATEMENTS
MADE ON THIS REQUEST FOR PATIENT FINANCIAL INFORMATION.
(Date) (Signature of Patient or Representative)
PLEASE RETURN NO LATER THAN
(Relationship to Patient -If patient
Did not Sign)
*Include only those who are supported by current
income information provided.
Date Returned