1227 E. Rusholme Street, Davenport, Iowa 52803
Tel: 800-250-6020
For Services Provided By:
Genesis Medical Center Davenport
Genesis Medical Center Silvis
Genesis Medical Center DeWitt
Genesis Medical Center Aledo
Financial Assistance Application Instructions
Genesis Health System’s mission is to provide quality, compassionate care to all of those in need. Staying
true to this mission, Genesis provides a Financial Assistance program to all those in need in a fair nondiscriminatory manner. Funds are set aside annually to assist those patients who indicate financial need.
Requirements are based on percentages above the Federal Poverty Income Guidelines. This application
does not guarantee financial assistance, but begins the review process for consideration. Genesis Health
System-Silvis Campus and Genesis Medical Center Aledo offer uninsured Illinois residents alternative
financial discounts. Please contact a customer service representative for more information about uninsured
Illinois resident discounts. Customer Service representatives can be reached at 563-421-3408 or 800-2506020. To print a copy of the financial assistance application and instructions, visit www.genesishealth.com.
It is important to note you may also be able to receive free or discounted care. Completing this application
will help Genesis Health System determine if you can receive free or discounted services or other public
programs that can help pay for your healthcare. Please submit this application to the hospital.
If you are uninsured, a social security number is not required to qualify for free or discounted care.
However, a social security number is required for some public programs, including Medicaid. Providing a
Social Security Number is not required but will help the hospital determine whether you qualify for any
public programs.
Please complete this form and submit it to the hospital in person, by US mail, by electronic mail, or by fax to
apply for free or discounted care within 30 days of receipt of the application.
The following items should be considered:
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A complete application must be returned within 30 calendar days of your receipt of the
application.
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All necessary information must be included with the completed application. If additional
information is required, applicant will be contacted and will have 7 business days from
date contacted to provide the additional information. Failure to provide this information
within time limit guidelines will result in a denial of financial assistance.
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Responsible parties receiving help from anyone in regard to living expenses must include
a written statement from that party and a copy of their picture identification.
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Patients must have applied for medical benefits through the State Department of Human
services if they qualify. Proof of denial/coverage should be included with all other
documentation.
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Genesis reserves the right to request verification of income. Refusal to provide requested
information in time limit guidelines will result in denial of financial assistance.

Return a completed application to:
Genesis Medical Center
ATTN: Patient Financial Services Suite #2600 - FA
1401 West Central Park Avenue
Davenport, IA 52803
www.genesishealth.com
Financial Assistance will not be granted if:
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Any portion of an account balance is payable or expected to be payable by a third party. If
proceeds from litigation or settlement resulting from an accident, injury or legal
proceedings are received by the patient, reimbursement to the hospital of any financial
assistance will be required.
Any hospital balance is under $500. (Exception for Illinois Uninsured Discount) Multiple
account balances cannot be combined to meet minimum balance requirements.
Fraudulent information given at any time during the process. Examples include, but are not
limited to, giving fraudulent name, address, employer/employment, income, and assets.
Age of self balance is greater than 240 days.
The following items (when applicable) must be returned with the completed application. Send
copies of documents as originals will not be returned.
 Copy of photo identification or equivalent documentation
 Copies of 2 (two) most recent paycheck stubs or copy of most recent tax return or copy of
most recent W-2 form and 1099 forms or written income verification from an employer if
paid in cash
 Verification of monthly income from Social Security or Disability
 Verification of unemployment income
 Verification of pension and/or workers compensation benefits
 Copies of last 3 (three) months bank checking/savings statements
 A letter of support and a copy of the supporter’s photo identification if the applicant
receives help financially from another party
 Verification of Student Status
 Letter of decision regarding public funded health insurance
 Documentation showing the balance due on home (if you own)
These items are not required but may be included and taken into consideration:
 Documentation of outstanding medical bills
 Documentation of monthly pharmacy charges (medication expenses that occur each
month)
If approved for financial assistance, you will be contacted via mail. If application results in a denial,
a letter of appeal can be submitted and will be considered on a case-by-case basis. A written letter
of appeal must be provided within 14 days of receiving a denial. A written appeal does not
guarantee change of financial assistance decision.
For those persons that do not qualify for financial assistance based on current guidelines,
extended interest-free payment plans are available. Please contact the business office to
discuss your specific options.
Failure to return any required portion of this application or supporting documents may result in a
denial of financial assistance. It is the patient’s responsibility to contact Genesis if additional time is
needed to gather necessary and required documentation.
Services Provided By:
 Genesis Medical Center Davenport
 Genesis Medical Center Silvis
 Genesis Medical Center DeWitt
 Genesis Medical Center Aledo
1227 E. Rusholme Street, Davenport, Iowa 52803
Tel 800-250-6020
FINANCIAL ASSISTANCE APPLICATION
Internal Use Only:
FA
SELF UNC____
I am requesting financial assistance in paying for health care services provided by Genesis. I understand
I must provide certain information for a review and a determination of my eligibility. I further understand
that completing this form does not guarantee any assistance. All information must be completed.
 Financial Assistance  IL Discount Both
Patient Name:
Patient Employer:
Patient Address:
Employer Address:
Patient Phone:
Employer Phone:
Patient SSN:
Patient Date of Birth:
Marital Status:  Single  Married
 Widowed
 Divorced  Separated
Responsible Party (guarantor) for payment of the bill:
Guarantor Name:
Guarantor Employer:
Guarantor Address:
Employer Address:
Guarantor Phone:
Employer Phone:
Guarantor SSN:
Guarantor Date of Birth:
Marital Status:  Single  Married
 Widowed
 Divorced  Separated
Number of Dependents:
Dependents Name:
Age: Dependents Name:
Age:
Dependents Name:
Age: Dependents Name:
Age:
Dependents Name:
Age: Dependents Name:
Age:
Resources (Income / Assets for the guarantor family)
Wages (Self)
(Spouse)
(Other family member)
Farm or self-employment
Public assistance
Social Security
Unemployment compensation
Strike benefits
Alimony
Child support
Military family allotments
Pensions
Income from dividends, interest, rent
Indicate: Monthly/Annual
____________
Expenses / Liabilities (Monthly) for Guarantor Family
Mortgage/Rent
*
Medical insurance
Utilities
Auto insurance
Telephone
Medical bills
Food
Hospital
Finance companies
Physician
Credit union
Medication
Auto loans
_______________
_______________
_______________
_______________
_______________
Total Expenses ___________________
* If none, source of housing
Do you own a home?
Yes ( ) No ( )
If yes, estimated value:
Amount owed on mortgage:
Additionally, please provide copies of the following Document:
__ Drivers License or Identification Card
__ Proof of all Outstanding Medical Bills
__ Last two paycheck stubs or documentation of unemployment –or__ Your last filed Federal or State Income Tax form, completed and signed –or__ Copy of Bank Statements
__ Decision regarding application for Medicaid / title 19 coverage (If applicable)
__ Proof of any other income received in the last 30 days
__ Other:
ACKNOWLEDGEMENT AND SIGNATURE:
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I declare under penalty of perjury and cancellation of any previous agreements that the answers I have provided
are true and correct to the best of my knowledge.
I agree to inform the provider of services, within 10 days, if there are any changes in my (or the persons on whose
behalf I am acting) income, property, expenses, or in the persons in the household, or of any changes of address.
I understand and grant permission for Genesis Health System, its affiliates and representatives to investigate and
verify all information provided within this application. All statements will be subject to verification by contact with
my employer, bank, credit bureaus, and record searches.
I understand Genesis is required by law to keep all submitted information confidential.
I further agree, that in consideration for receiving healthcare services as a result of an accident or injury, to
reimburse the hospital from proceeds of any litigation or settlement resulting from such act.
I understand that if I do not qualify for uncompensated services, I will be personally liable for the charges of the
services rendered by Genesis or I may appeal the decision in writing with additional documentation.
I understand that it is my responsibility to inform the hospital of future visits that should be considered for Financial Assistance.
Signature
Date