New Entry: Apply for Community Care – Jamestown Regional Medical Center

Step one: Complete Application

Your application may be denied and returned if not completed properly.

Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

SSN (xxx-xx-xxxx) *

Do you have a co-applicant? *

YES
NO

Optional Details

This may aid you in qualifying for a federal or state assistance program such as Medicaid or Disability.

Are you pregnant?

YES
NO

Are you disabled?

YES
NO

Do you have dependents?

YES
NO

Income and Other Assets

Monthly Net Income (Please Fill in Dollar Amount Where Acceptable)

Income *

Spouse's Income

Alimony/Child Support

Rental Income

Other

Assets (Please Fill in Dollar Amount Where Acceptable)

Life Insurance Cash Value

Stocks/Bonds/Mutual Funds

Retirement Plans

Saving Accounts

Real Estate (Net Cash Value)

Other

Income Taxes

Which applies to you? *

I have not filed for income taxes in the past two years due to low-income status.
I am up-to-date on my income tax filing.

Partial Community Care Agreement

Payment plans arranged with partial Community Care Application awardees are considered reasonable by the Patient Accounts Coordinator.

I promise to pay Jamestown Regional Medical Center (JRMC) the remainder of my bill if I receive Partial Community Care to cover a portion of my current bill. If I default on this plan, I know that the hospital can take action to see that they are paid for the services that were offered including, but not limited to, sending my account to a collection agency. The information stated in this application is correct to the best of my knowledge. You are authorized to check my credit and employment history and to answer questions about your credit experience with me. You are further authorized to disclose any information contained herein and other information obtained by you with regard to my credit and employment history to third parties, solely for the purpose of obtaining financing for payment of any indebtedness that might owe you. By checking the box below, I am promising to cooperate with the hospital staff and provide adequate information in a timely mater to get my bill resolved. I understand that by checking the box below, I'm giving JRMC the right to verify this information and deny me of Community Care if I am fraudulent.

Checkboxes *

I acknowledge that I've read and reviewed the Community Care guidelines and financial assistance policy.

Date *

Step Two: Gather, Copy and Scan Documents

By presenting proof, your eligibility can be better assessed. These materials include:

-income taxes for the past two years(if you don't file income taxes, please provide your two most recent W-2 forms or the last six pay stubs from your employer included in this packet to verify that they were not filed)

-additional documentation of income needed for verification if you are: receiving income from another source such as SS. retirement, alimony, child support, VA or welfare, or making payments to another source such as alimony or child support

-three recent bank statements

-six recent pay stubs

-Notification of Benefit Decision from the ND Department of Health and Human Services

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