Financial Assistance Application


Please note that all fields marked * are required.

Patient Information:
First Name*  
Last Name*  
Address*  
Address 2  
City*  
State*  
Zip*  
Social Security #*  
Phone*    
What MHP facility will you be/or have  
you received services at?*  


Employment Information:
Name of Employer*  (Patient/Guarantor)    
Date Hired*  (Patient/Guarantor)    (mm/dd/yyyy)
Date Employment Ended  (Patient/Guarantor)    (mm/dd/yyyy)
Name of Employer (Spouse)  
Date Hired (Spouse)    (mm/dd/yyyy)
Date Employment Ended (Spouse)    (mm/dd/yyyy)

If zero income is reported, please  
provide an explanation of how  
patient is supporting self.  


Income Information:
Name
Age
Relation To Patient*
Gross Income 3 months prior
to date of service
Gross Income 12 months prior
to date of service
Current Gross Income
Type of Income**
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$




*Family includes immediate family who live in your home such as patient, patient's spouse, all of patient's children under 18 (natural or adoptive) who live in patient's home. Patients under 18 include parental income.

**Types of income included but not limited to: Wages, self employment, social security, unemployment,child support, alimony, workers comp, pension, VA benefits.

You will be contacted within 5 to 10 business days by a Mercy representative to discuss your application.

Please be prepared to provide income verification: pay stubs, w-2's, self-employment records, award letter, bank statement showing direct deposit, or any document containing income information.