QHS Financial Assistance Application

Prior to beginning, please gather the following documents, you will be submitting them later on in this application:

• Your driver’s license, birth certificate and/or other picture ID or alien card
• Three most current pay stubs
• Bank/Credit Union statements for current month and two previous months (checking and savings if applicable)
• Social Security Income (SSI) award letter for the current year
• Appraisals or ownership documents for property, motor vehicles, stocks and bonds, jewelry, life insurance and items of value; and provide verifications of any balance due
• Receipts for rent and any expenses

I certify that the above is true and correct and is a complete list of all income/assets and expenses/liabilities. You are authorized to obtain such information as you may require to verify the accuracy of the above statements and representations. I understand that any intentional omissions of information will disqualify me from any Discounted Care Program offered by the Queen’s Medical Center or subject me to legal action to recover discounted care already approved.

If you request that the hospital or its affiliates extend additional financial assistance, the hospital or affiliate may request additional information in order to make a supplemental determination. By signing this form, you certify that the information provided is true and agree to notify the hospital or affiliate of any changes to the information within ten days of the change.