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New Entry: Apply for Community Care
Thank you for applying for Community Care. We appreciate your time and look forward to seeing you! We will be in touch within two to three business days.
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Step
1
of 4
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
North Dakota
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Email
*
SSN (xxx-xx-xxxx)
*
Do you have a co-applicant?
*
YES
NO
Name
*
First
Last
Date of Birth
*
Address
*
Address Line 1
Address Line 2
City
North Dakota
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Email
*
SSN
*
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
Please List All Your Dependents
*
(Name, Relationship to You, and Age For Each Dependent)
NEXT
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
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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
*
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NEXT
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
File Upload
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File Upload
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File Upload
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Comments
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