[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-568721-105":53,"doc-detail-568721-en":118},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":111,"head_meta":113,"extra_data":115,"updated_unix":117},105,"en","trinity-health-financial-assistance-application-confidential-form","Trinity Health Financial Assistance Application - Confidential Form","","Confidential financial assistance application for hospital and professional services provided by Trinity Health and St. Mary’s Health Care System. Requires completion within 10 days and submission of required verifications, including proof of gross income, complete bank statements, recent tax returns or profit and loss statements, and optional documents such as W2, unemployment letters, and child support/alimony details. Collects patient demographics, tax filing and dependent status, health insurance coverage, and household member information. Includes income verification and a signed support letter when applicable, plus a patient or legal guardian certification with signature and date.",{"@graph":63,"@context":110},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/trinity-health-financial-assistance-application-confidential-form/568721/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/trinity-health-financial-assistance-application-confidential-form/568721.png","ImageObject",442,249,{"name":88,"@type":89},"Quinn Holloway","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-16","2026-10-13",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104],{"name":105,"@type":106,"acceptedAnswer":107},"What information must be provided about the patient and household members?","Question",{"text":108,"@type":109},"The form collects patient identity and demographics, tax filing and dependent status, health insurance coverage at the time of service, and whether the patient is a documented U.S. resident. It also gathers household member details and income sources with gross monthly amounts before taxes.","Answer","https://schema.org",{"og:url":78,"og:type":112,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":114,"canonical":78},"index,follow",{"doc_id":116,"site_id":56},568721,1792124003,{"code":4,"msg":5,"data":119},{"doc_id":116,"user_id":120,"nickname":88,"user_avatar":121,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":122,"file_id":123,"file_url":124,"file_type":125,"file_size":126,"view_count":9,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":127,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":128,"faqs":129,"seo_title":130,"seo_description":61,"update_tm":131,"read_time":73},2336474466712,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","[CONFIDENTIAL APPLICATION FOR FINANCIAL ASSISTANCE]  \n[For Hospital and Professional services provided by facilities and physicians of Trinity Health] Personal & Confidential  \nGuarantor:  \nCase Number:  \nPatients Included in Case:  \nThank you for selecting St. Mary’s Health Care System as your health care provider. Please complete the enclosed application and return to the address below to complete the evaluation of your financial assistance.  \nIf you have any questions, please contact our Customer Service Center at 800-494-5797, Monday through Friday between 9:00 a. m. -5:00 p. m. ET.  \nSincerely,  \nTrinity Health Enterprise Patient Financial Services  \nOn behalf of St. Mary’s Health Care System  \n20555 Victor Parkway  \nLivonia, MI 48152  \n[CONFIDENTIAL APPLICATION FOR FINANCIAL ASSISTANCE]  \n[For Hospital and Professional services provided by facilities and physicians of Trinity Health]  \n\n| [Please complete and sign application form and return within 10 days including copies of the following:] |  |  |  |\n| --- | --- | --- | --- |\n| [ Required Verifications]\u003Cbr>☐ [Past One month Proof of Gross Income]\u003Cbr>☐ [Past Two months Complete Bank Statements for all bank accounts, with all pages included (explanation for recurring deposits)]\u003Cbr>☐ [Recent Tax Returns (1040 form with Schedule C, E or F) or Three Months Profit and Loss Statements (for selfemployed/dependents)]\u003Cbr>[ Provide the following, If applicable]\u003Cbr>☐ [Recent W2 for Seasonal Income] ☐ [Unemployment Benefit/ Denial letter] ☐ [Child Support Income/Alimony]☐ [No Income – Complete Letter of Financial Support portion of the application] |  |  |  |\n| Patient Information |  |  |  |\n| [Patient Name] |  | [Date of Birth] |  |\n| [Social Security/EIN Number (optional)] | [Mobile Phone] | [Other Phone] |  |\n| [Mailing Address] | [City] | [State] | [ZIP code] |\n| [Email Address] | [Of what state are you a resident?] |  |  |\n| [Marital status] □[Single] □[Married] □[Divorced] □[Other]   |  |  |  |\n| [Do you file a Federal Tax Return?] □ [Yes] □ [No][If no, why?] | [Can you be claimed as dependent on someone else's tax return?] □ [Yes] □ [No] |  |  |\n| [Did you or your dependents have health insurance coverage at the time of service?\u003Cbr>□ [Yes] □[No] [(Provide Insurance card copy) |  |  |  |\n| [Are you a documented resident of the United States? □ [Yes] □ [No] □ [Prefer Not to Answer] |  |  |  |\n\n[CONFIDENTIAL APPLICATION FOR FINANCIAL ASSISTANCE]  \n[For Hospital and Professional services provided by facilities and physicians of Trinity Health]  \n\n| [Household Members, including yourself based on your recent Tax Returns] |  |  | [Date of Birth] | [Relationship to Patient] |  | [Claimed on Tax Return (Yes/No)] |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n| [Income Verification for all household members] |  |  |  |  |  |  |  |\n| [Monthly Income Source] | [Who receives this?] | [Gross Monthly Income (before taxes)] |  | [Monthly Income Source] | [Who receives this?] |  | [Gross Monthly Income (before taxes)] |\n| [Wages] |  |  |  | [Worker’s Compensation] |  |  |  |\n| [Social\u003Cbr>Security/Disability] |  |  |  | [Unemployment] |  |  |  |\n| [Pension] |  |  |  | [Child Support/Alimony] |  |  |  |\n| [Self-Employment] |  |  |  | [Rental Land Income] |  |  |  |\n| [Public Assistance] |  |  |  | [Other] |  |  |  |\n| [Letter of Financial Support-Should only be completed by the person providing support] |  |  |  |  |  |  |  |\n\n[CONFIDENTIAL APPLICATION FOR FINANCIAL ASSISTANCE]  \n[For Hospital and Professional services provided by facilities and physicians of Trinity Health]  \n\n| ☐ [I provide more than 50% support for the patient's living expenses, but I am unable to help with medical bills.]\u003Cbr>☐ [By signing this letter, I verify that the above statement is correct and that I will in no way be held liable for the patient's bills. If you have questions, ple","cbCaioYODo3Je5zO","https://ap.wps.com/l/cbCaioYODo3Je5zO","pdf",801547,"English","# Required submission timeline\n## Required verifications within the application\n# Patient information\n## Demographics and tax-related questions\n# Household members and income verification\n## Monthly income sources by household member\n# Letter of financial support\n## Support provider confirmation and signature\n# Income and identification verification","[{\"question\":\"What information must be provided about the patient and household members?\",\"answer\":\"The form collects patient identity and demographics, tax filing and dependent status, health insurance coverage at the time of service, and whether the patient is a documented U.S. resident. It also gathers household member details and income sources with gross monthly amounts before taxes.\"}]","Trinity Health Financial Assistance Application - Confidential Form | PDF",1791872089]