Charity Care - Northern Illinois Cancer Treatment Center

Northern Illinois Cancer Treatement Center

a non-profit organization

815.284.1111

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Charity Care

Healing. Hope. Here.

Apply Today

Thank you for your knowledge, your talent, your thoughtfulness and your heart during this difficult time in my life. - Elizabeth

Chartiy Care Application

Fill out the form below to apply for charity care through Northern Illinois Cancer Treatment Center.

Patient Information

First Name
Last Name
Date of Birth
Street Address
Apt or Unit # (if needed)
City
State
Zip Code
Phone Number
Social Security Number
Marital Status
Do you have minor children (under 18)? Yes No

Do they live with you? Yes No Are they your birth/legally adopted children? Yes No

Patient Employed? Yes No

Date of Last Employment?

Spouse Employed? Yes No

Date of Last Employment?

Do you have Medical Insurance? Yes No Are you on disability? Yes No

How Long?

Are you a Veteran? Yes No

Family Members

How many family members live with you?

Spouse:
Child:
Child Age:
Child:
Child Age:
Child:
Child Age:
Child:
Child Age:
Child:
Child Age:
Other:

Income (Gross Monthly Amounts)

Patient
Spouse
Dependants
Public Assistance
Food Stamps
Social Security
Unemployment
Strike Benefits
Workers' Compensation
Alimony
Child Support
Military Allotments
Pensions
Income from CD's, Rent, Dividends, ect...
Interest
Income Total

Expenses (Gross Monthly Amounts)

Rent/Mortgage
Homeowner's Insurance
Property Tax
Electric
Gas/Propane
Water
Telephone/Cell
Food
Car Payment
Car Insurance
Gasoline
Alimony/Child Support
Child Care
Clothing
Charge Cards (Monthly Total of all Cards)
Loans
Medical Insurance
Life Insurance
Cable/Satellite
Other
Expenses Total

Assets (Gross Totals)

Checking Account
Savings Account
CD's
IRA's
Investments Stocks/Bonds
Property (other than your primary residence)

Vehicles

Auto 1 Year/Make
Auto 1 Estimated Value
Auto 2 Year/Make
Auto 2 Estimated Value
Motorcycle Year/Make
Motorcycle Estimated Value
Boat Year/Make
Boat Estimated Value
Recreational Vehicle Year/Make
Recreational Vehicle Estimated Value

Medical Bills

Doctors (Total Owed)
Doctors (Monthly Payment)
Medicines (Total Owed)
Medicines (Monthly Payment)
Hospital (Total Owed)
Hospital (Monthly Payment)
Other (Total Owed)
Other (Monthly Payment)

Employment (Patient)

Name of Employer
Employer Telephone Number
Employer Street Address
Suite or Unit # (if needed)
Employer City
Employer State
Employer Zip Code
Occupation

Employment (Spouse)

Name of Employer
Employer Telephone Number
Employer Street Address
Suite or Unit # (if needed)
Employer City
Employer State
Employer Zip Code
Occupation

Other Aid

Are you currently applying for Medicaid Benefits? Yes No Have you applied for assistance thru your county hospital/indigent program? Yes No Is anyone assisting you with payment of Medical Bills? Yes No

Who is Assisting You?
How much assistance are you receiving?

Charity Care Policy

I have read and agree with the terms and conditions listed above.

Signature
Signature Date

Extra Comments or Notes