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Financial Assistance Application

911 Bypass Road, Building A Pikeville, KY  41501 606-430-3303


Click here to download a printable application. Fill out and return to the address listed at the top. A phone number is listed for questions. Otherwise, fill out the online application below.

Financial Assistance Application

Submit your financial assistance application using the secure form below.

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Mobile Form

PATIENT AND FAMILY INFORMATION
Patient Name: *
SSN: *
Date of Birth: *
Mailing Address: *
City, State, Zip: *
Telephone #: *
Spouse/Guarantor Name:
SSN:
Date of Birth:
Mailing Address:
City, State, Zip:
Telephone #:
Dependents (If Over 19, copy of tax return or full-time status is required)
Dependent 1:
SSN:
Age:
DOB:
Dependent 2:
SSN:
Age:
DOB:
Dependent 3:
SSN:
Age:
DOB:
Dependent 4:
SSN:
Age:
DOB:
EMPLOYMENT INFORMATION
Patient Employer:
Hourly Wage:
Do not enter a dollar sign
Hours/Week:
Spouse/Guarantor Employer:
Hourly Wage:
Do not enter a dollar sign
Hours/Week:
TOTAL OTHER INCOME
Social Security:
Do not enter a dollar sign
Pensions:
Do not enter a dollar sign
Supplemental Security Income (SSI):
Do not enter a dollar sign
Other (Interest, Rental, Alimony, etc):
Do not enter a dollar sign
Worker's Compensation:
Do not enter a dollar sign
Unemployment:
Do not enter a dollar sign
Food Stamps (Not counted):
Do not enter a dollar sign
Total Income:
Do not enter a dollar sign
COUNTABLE ASSETS/RESOURCES
Bank Accounts - Name of Bank:
Checking:
Do not enter a dollar sign
Savings:
Do not enter a dollar sign
CD:
Do not enter a dollar sign
Credit Union - Name:
Checking:
Do not enter a dollar sign
Savings:
Do not enter a dollar sign
CD:
Do not enter a dollar sign
OTHER ASSETS
Investments:
Do not enter a dollar sign
Money Market Accounts:
Do not enter a dollar sign
Savings Bonds:
Do not enter a dollar sign
Other:
Do not enter a dollar sign
HOUSEHOLD EXPENSES
Rent/Mortgage:
Do not enter a dollar sign
Loan/Lease Payment (1 Vehicle):
Do not enter a dollar sign
Insurance Premiums:
Do not enter a dollar sign
Telephone (1 Landline or Cell Phone):
Do not enter a dollar sign
Trash:
Do not enter a dollar sign
Electricity:
Do not enter a dollar sign
Water:
Do not enter a dollar sign
Sewer:
Do not enter a dollar sign
Natural Gas:
Do not enter a dollar sign
I hereby state that the above information is true and correct to the best of my knowledge. By signing this document, I agree to notify Pikeville Medical Center of any changes in my financial position.
Patient's Signature: *

YOU MUST SUBMIT THE FORM TO SAVE YOUR DATA.

Desktop Form

PATIENT AND FAMILY INFORMATION
Patient Name: *
SSN: *
Date of Birth: *
Mailing Address: *
City, State, Zip: *
Telephone #: *
Spouse/Guarantor Name:
SSN:
Date of Birth:
Mailing Address:
City, State, Zip:
Telephone #:
Dependents (If Over 19, copy of tax return or full-time status is required)
Dependent 1:
SSN:
Age:
DOB:
Dependent 2:
SSN:
Age:
DOB:
Dependent 3:
SSN:
Age:
DOB:
Dependent 4:
SSN:
Age:
DOB:
EMPLOYMENT INFORMATION
Patient Employer:
Hourly Wage:
Do not enter a dollar sign
Hours/Week:
Spouse/Guarantor Employer:
Hourly Wage:
Do not enter a dollar sign
Hours/Week:
TOTAL OTHER INCOME
Social Security:
Do not enter a dollar sign
Pensions:
Do not enter a dollar sign
Supplemental Security Income (SSI):
Do not enter a dollar sign
Other (Interest, Rental, Alimony, etc):
Do not enter a dollar sign
Worker's Compensation:
Do not enter a dollar sign
Unemployment:
Do not enter a dollar sign
Food Stamps (Not counted):
Do not enter a dollar sign
Total Income:
Do not enter a dollar sign
COUNTABLE ASSETS/RESOURCES
Bank Accounts - Name of Bank:
Checking:
Do not enter a dollar sign
Savings:
Do not enter a dollar sign
CD:
Do not enter a dollar sign
Credit Union - Name:
Checking:
Do not enter a dollar sign
Savings:
Do not enter a dollar sign
CD:
Do not enter a dollar sign
OTHER ASSETS
Investments:
Do not enter a dollar sign
Money Market Accounts:
Do not enter a dollar sign
Savings Bonds:
Do not enter a dollar sign
Other:
Do not enter a dollar sign
HOUSEHOLD EXPENSES
Rent/Mortgage:
Do not enter a dollar sign
Loan/Lease Payment (1 Vehicle):
Do not enter a dollar sign
Insurance Premiums:
Do not enter a dollar sign
Telephone (1 Landline or Cell Phone):
Do not enter a dollar sign
Trash:
Do not enter a dollar sign
Electricity:
Do not enter a dollar sign
Water:
Do not enter a dollar sign
Sewer:
Do not enter a dollar sign
Natural Gas:
Do not enter a dollar sign
I hereby state that the above information is true and correct to the best of my knowledge. By signing this document, I agree to notify Pikeville Medical Center of any changes in my financial position.
Patient's Signature: *

YOU MUST SUBMIT THE FORM TO SAVE YOUR DATA.

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