608 829 5254-2026

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The document is a Financial Statement form for the Community Care program at the University of Wisconsin Medical Foundation and Hospital. It collects detailed information about patients' financial situations, including family members with patient balances, income sources, assets, monthly expenses, and medical bills owed. The form aims to assess eligibility for financial assistance while ensuring confidentiality of the provided information.

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Click ‘Get Form’ to open the Financial Statement in the editor.
Begin by entering your personal information in the designated fields, including your name and the date completed.
List all family members with patient balances for consideration in the Community Care program. Fill in their names, medical record numbers, and birth dates as required.
Provide details about the guarantor and spouse, including relationship to patient, addresses, and employment information.
Indicate marital status by checking the appropriate box and provide monthly income details for both the guarantor and spouse if applicable.
Complete sections on assets, household expenses, and any outstanding medical bills. Ensure all fields are filled accurately.
Review your entries for accuracy before signing at the bottom of the form. Make sure to attach any required documents as specified.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (116 Votes)

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