Financial Assistance Application

911 Bypass Road,
Building A
Pikeville, KY 41501
606-430-3303

Click here to download a printable application. Fill out and return to the address listed at the top. A phone number is listed for questions. Otherwise, fill out the online application below.

Online Financial Assistance Application

PATIENT AND FAMILY INFORMATION
Patient Name: ^*
SSN: ^*
Month/Day of Birth: ^*
Mailing Address: ^*
City, state, zip: ^*	,
Telephone #: ^*
Spouse/Guarantor Name:
SSN:
Month/Day of Birth:
Mailing Address:
City, state, zip:
Telephone #:
Dependents (If Over 19, copy of tax return or full time status is required)
Dependent 1:
Dependent 1 Age:
Dependent 1 DOB:
Dependent 1 SSN:
Dependent 2:
Dependent 2 Age:
Dependent 2 DOB:
Dependent 2 SSN:
Dependent 3:
Dependent 3 Age:
Dependent 3 DOB:
Dependent 3 SSN:
Dependent 4:
Dependent 4 Age:
Dependent 4 DOB:
Dependent 4 SSN:
EMPLOYMENT INFORMATION
Patient Employer:
Hourly Wage:	$
Hours/Week:
Spouse/Guarantor Employer:
Hourly Wage:	$
Hours/Week:
TOTAL OTHER INCOME
Social Security:	$
Pensions:	$
Suplemental Security Income: (SSI):	$
Other (Interest, Rental, Alimony, etc):	$
Worker's Compensation:	$
Worker's Compensation:	$
Food Stamps: (Not counted)	$
COUNTABLE ASSETS/RESOURCES
Bank Accounts - Name of Bank:
Checking:	$
Savings:	$
CD:	$
Credit Union - Name:
Checking:	$
Savings:	$
CD:	$
OTHER ASSETS
Investments:	$
Money Market Accounts:	$
Savings Bonds:	$
Other:	$
HOUSEHOLD EXPENSES
Rent/Mortgage:	$
Loan/Lease Payment (1 Vehicle):	$
Insurance Premiums:	$
Telephone (1 Landline or Cell Phone):	$
Trash:	$
Electricity:	$
Water:	$
Sewer:	$
Natural Gas:	$
I hereby state that the above information is true and correct to the best of my knowledge. By signing this document, I agree to notify Pikeville Medical Center of any changes in my financial position.
Patient's Signature^*
YOU MUST CLICK THE BOX BELOW. IF YOU FAIL TO DO SO, ALL THE DATA YOU HAVE ENTERED MAY BE LOST.

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PATIENT AND FAMILY INFORMATION
Patient Name: ^*		SSN: ^*	DOB: ^*
Mailing Address: ^*		City, State Zip: ^*
Telephone #: ^*
Spouse/Guarantor Name:		SSN:	DOB:
Mailing Address:		City, State Zip:
Telephone #:
Dependents (If Over 19, copy of tax return or full time status is required)
Dependent 1:	SSN:	Age:	DOB:
Dependent 2:	SSN:	Age:	DOB:
Dependent 3:	SSN:	Age:	DOB:
Dependent 4:	SSN:	Age:	DOB:
EMPLOYMENT INFORMATION
Patient Employer:		Hourly Wage: $	Hours/Week:
Spouse/Guarantor Employer:		Hourly Wage: $	Hours/Week:
TOTAL OTHER INCOME
Social Security:	$	Worker's Compensation:	$
Pensions:	$	Unemployment:	$
Suplemental Security Income: (SSI):	$	Food Stamps: (Not counted)	$
Other (Interest, Rental, Alimony, etc):	$
		Total Income	$
COUNTABLE ASSETS/RESOURCES
Bank Accounts - Name of Bank:
Checking: $	Savings: $	CD: $
Credit Union - Name:
Checking: $	Savings: $	CD: $
Investments:	$	Money Market Accounts:	$
Savings Bonds:	$	Other:	$
HOUSEHOLD EXPENSES
Rent/Mortgage:	$	Electricity:	$
Loan/Lease Payment (1 Vehicle):	$	Water:	$
Insurance Premiums:	$	Sewer:	$
Telephone (1 Landline or Cell Phone):	$	Natural Gas:	$
Trash:	$
I hereby state that the above information is true and correct to the best of my knowledge. By signing this document, I agree to notify Pikeville Medical Center of any changes in my financial position.
Patient's Signature^*
YOU MUST CLICK THE BOX BELOW. IF YOU FAIL TO DO SO, ALL THE DATA YOU HAVE ENTERED MAY BE LOST.

>>><<<

Financial Assistance Application

Online Financial Assistance Application

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