St Mary Medical Center
Customer Service Department
1201 Langhorne-Newtown Road
Langhorne, PA 19047
215-710-6546 (p
)
215-710-5734 (f)
Dear _____________________________ Date ______________________________
Attached is a Financial Assistance Application. Please provide the supporting documentation which reflects your personal
situation. Failure to submit all requested information may result in denial of your application. Your application must include
copies of any of the following documents. Please attach copies, not originals as St. Mary Medical Center cannot return any
documents sent with the application. Applications not returned within 30 days may be denied
APPLICANT AND SPOUSE
Please note that documentation is required for both adult applicant and spouse. If you are divorced or sepa
rated,
p
lease provide verification. If you receive or pay out alimony or child support, please provide supportiv
e
d
ocum
ents
DEPENDENTS
Any dependent over the age of 18 must include proof of full time student st
atus
o Cu
rrent semester roste
r
PR
OOF OF INCOME: (Please provide each of the following or an explanation of why not provided)
Federal Income Tax Return(s) for your household for the most recent calendar year
.
Two (2) full months of Bank Statements for all bank accounts for the last 2 months (savings and
checking).
O
ne (1) month most recent pay stubs- or a statement from your employer regarding your income
.
o I
f self-employed, please provide a copy of your last quarter’s Business Financial Statement along with th
e
p
revious year’s Business Tax Return and Profit and Loss Statem
ent
o Unemployment statement showing denial or eligibility and amount receiving.
So
cial Security Income or Social Security Disability provide a copy of your notification from Social Securit
y
in
dicating your monthly benefits for the current year.
Written documentation of all forms of income. (I.e. trust funds, stock dividends, child support, alimony, socia
l
security, public assistance, food stamps, etc.)
o If you have not had any income for the past three (3) months or there has been a recent change in you
r
f
inancial situation you must include a statement or letter explaining your situation. If someone else i
s
s
upporting you, they must sign the support statement on page 6 of the application
.
An
y other information that demonstrates financial hardship or need for financial assistance (i.e. public assistanc
e
award, or denial letters, letters of support etc.)
IDENTIFICATION AND PROOF OF RESIDENCY
One (1) form of government issued photo identification. (i.e. driver’s license, government issued photo ID, or
p
assport
)
One (
1) form of the following for proof of residenc
y
o Cu
rrent Utility
Bill
o Co
py of rental/lease agreem
ent
o M
ortgage Statem
ents
o Copy of Auto insurance card
M
EDICAL INSURANCE
Copy of medical insurance cards for all family member
s
S
end completed, signed and dated applications and documentation to:
1201 Langhorne-Newtown Road
2 Revised October 2018