Eastern Maine Healthcare Systems
Application for Free Care
For Medically Necessary Services Only
1. FACILITY WHERE MEMBERS OF YOUR HOUSEHOLD RECEIVES CARE:
2. PATIENT/APPLICANT
NAME:
SSN:
CELL/HOME PHONE:
ADDRESS:
DOB:
MARITAL STATUS:
3. SIGNIFICANT OTHER/CO-APPLICANT
NAME:
SSN:
DOB:
CELL/HOME PHONE:
ADDRESS:
EMMC
INLAND
Acadia
TAMC
EMPLOYMENT INFORMATION
EMPLOYER NAME:
HIRE DATE:
JOB TITLE:
PHONE:
ADDRESS:
CADEAN
SVH
BHMH
NOT EMPLOYED?
LAST DATE WORKED:
PLEASE EXPLAIN:
MR#:
NOT EMPLOYED?
LAST DATE WORKED:
(Office Use)
EMPLOYMENT INFORMATION
EMPLOYER NAME:
HIRE DATE:
JOB TITLE:
PHONE:
ADDRESS:
MARITAL STATUS:
PLEASE EXPLAIN:
(Office Use)
4. DEPENDANTS IN THE HOUSEHOLD
RELATIONSHIP
DATE OF BIRTH
APPLICANT
CO-APPLICANT
5. GROSS HOUSEHOLD MONTHLY INCOME
WAGES & SALARIES
DIVIDENDS / INTEREST / RENTAL INCOME
SHORT/LONG TERM DISABILITY
BUSINESS/SELF-EMPLOYMENT
SOCIAL SECURITY INCOME/RETIREMENT
SOCIAL SECURITY DISABILITY (SSDI)
WORKERS COMPENSATION
MILITARY / PENSION
UNEMPLOYMENT BENEFITS
ALIMONY / CHILD SUPPORT
OTHER INCOME:
TOTALS
7. MONTHLY EXPENSES/LIABILITIES
RENT / MORTGAGE PAYMENT
OTHER MORTGAGE PAYMENTS
PERSONAL OR STUDENT LOANS
CHARGE ACCOUNTS
PRESCRIPTIONS, MEDICAL BILLS
ELECTRICITY, WATER, PHONE, GROCERIES
OTHER EXPENSES:
$
√ IF IN
HOUSEHOLD
TOTALS
BALANCE DUE
(Office Use) MR#
6. HOUSEHOLD ASSETS
CASH
CHECKING ACCOUNT
SAVINGS ACCOUNT
LIFE INSURANCE VALUE
ANNUITIES BALANCE
STOCKS & BONDS VALUE
PROPERTY–YEARS OWNED
VEHICLES (YEAR/MAKE)
OTHER VEHICLES VALUE
BUSINESS EQUIP VALUE
OTHER ASSETS:
$
MONTHLY
PAYMENTS
MR#:
√ IF CLAIMED
ON TAXES
$
8. INSURANCE INFORMATION
HAS ANYONE IN THE HOUSEHOLD APPLIED FOR
MAINECARE IN THE PAST 3 MONTHS? _______
IF YES: ATTACH COPY OF DETERMINATION LETTER
DOES ANYONE IN THE HOUSEHOLD HAVE
INSURANCE? _______
IF YES: ATTACH COPY OF CARD/S
TOTALS
9. SIGNATURES
_____________________________________________
PATIENT/APPLICANT
Sign Here
_____________________________________________
DATE
CO-APPLICANT
I/We certify that all the information provided is true and complete.
DATE