Hennepin Care Application Form

Head of Household or Guarantor Information
Adult 1
Reference #:
Date:
 
Patient name:
Social Security# (secure):
Patient DOB:
 
Medical Record #:
 
Address:
 
Apartment #:
 
City:
 
State:
 
Zip Code:
 
eMail:
 
Telephone:
 
County of residence:
 
Marital status:
 
Are you applying for a Hennepin Care discount?
 
yes no
 
Spouse and Legal Dependents 
Last name
First name
DOB
Relationship
MRN
Applying for Hennepin Care discount?
yes no
yes no
yes no
  
Citizenship
Is everyone applying a US citizen or US National?
 
yes no, if no complete section below.
Last name
First name
Immigration status
Date entered the US
Employment/Work History - Head of Household
Please include all employment information for the past 30 days.
Employee initials:
    
Employer 1 name:
Address:
Telephone:
Start date:
End date:
  
$ hourly rate:
hours/week:
How often paid?
Do you receive tips:
yes no
if yes amount/month:
  
      
Employee initials:
    
 
Employer 2 name:
Address:
Telephone:
Start date:
End date:
  
$ hourly rate:
hours/week:
How often paid?
Do you receive tips:
yes no
if yes amount/month:
  
      
Employee initials:
    
 
Employer 3 name:
Address:
Telephone:
Start date:
End date:
  
$ hourly rate:
hours/week:
How often paid?
Do you receive tips:
yes no
if yes amount/month:
  
      
Employee initials:
    
 
Employer 4 name:
Address:
Telephone:
Start date:
End date:
  
$ hourly rate:
hours/week:
How often paid?
Do you receive tips:
yes no
if yes amount/month:
  
      
Other Income
Please submit supporting documentation with your completed application.
  
Monthly
Amount
  
Monthly
Amount
Child Support:
Unemployment:
Self-Employment Income - Self:
Alimony:
Self-Employment Income - Spouse:
Social Security:
Other Income:
   
      
No Income
If no income has been reported, explain in the box at right how you pay for your living expenses such as food, housing, clothing, and other things you need:


 
Liquid Assets
(Stocks, Bonds, Checking, Savings, Money Market, Certificate of Deposit accounts) Liquid asset information is not collected for outpatient discounts
Name of Financial
Institution
Account Type
Owner(s) Name
Current Balance
    
Certification
1.
I, the undersigned, certify that the completed information in this document is true and accurate to the best of my knowledge.
2.
I will apply for any and all assistance that may be available to help pay this bill.
3.
I understand the information submitted is subject to verification; therefore, I grant permission and authorize any bank, insurance co., financial institution and credit grantors of any kind to disclose to any authorized agent of Hennepin County Medical Center information as to my past and present accounts, policies, experiences and all pertinent information related thereto. I authorize Hennepin County Medical Center to perform a credit check for both responsible persons/patient and spouse.
4.
I understand that I might be asked to provide documentation to verify my information.
5.
If the application is incompleted, it will be returned. We will not be responsible for follow-up on incomplete applications.
6.
If you do not qualify for Hennepin Care program or have any copays or deposit balances remaining after 90 days from the service date your balance may be placed with a collection agency. If your balance is not paid to the collection agency.  Hennepin County Medical Center is authorized to place your balance with the Department of Revenue. During this time any state taxes, property taxes, or lottery winnings will be forwarded to HCMC to satisfy your outstanding balance.
  
As Patient/Guarantor, , I certify that checking this box the equivalent of my signature.
I agree.     Date:
As Patient/Guarantor Spouse, , I certify that checking this box the equivalent of my signature.
I agree.     Date: