Household Assets:

"Household Assets" include information on funds readily available to the Responsible Party and all individuals residing in the household as claimed on the Responsible Party's federal income tax return. Assets such as retirement funds, land, buildings, and vehicles are excluded and should not be reported below.

Other Considerations:

Responsible Party Explanation, Request, and Additional Information: *

Please use this section to explain any circumstance that makes payment of your financial responsibility a financial hardship. Please also provide any other information that you feel would be helpful in reviewing your request for assistance. You may also wish to attach additional documentation that may support your application.

If I am approved for financial assistance, The Children's Mercy Hospital reserves the right to reverse this discount should any third party payer or carrier pay on my account(s) partially or in its entirety. I understand that it is my responsibility to report to the Hospital, within 30 days, any change in my Household Income or other factors that may impact eligibility for financial assistance from the Hospital. I certify that the information given on this application and any attached supporting documentation is accurate and complete to the best of my ability. Should the Hospital become aware of any misrepresentation, I understand that any discount received will be reversed and I will be responsible for any remaining balance(s). I authorize the Hospital to investigate the information in reviewing my application for financial assistance and authorize the release of any information necessary to determine my eligibility.