BROAD STREET CLINIC FOUNDATION, INC
APPLICATION
DATE: ______________________      
NAME:
LAST:  
__________________________ FIRST: ______________ MIDDLE: _______________
BIRTHDATE:  
__________________________ SOCIAL SECURITY #: ___________________________
MAILING ADDRESS:
STREET:  
___________________________________________________________
CITY:  
__________________________ STATE: ___________________ ZIP: _____________
PHONE:
HOME:  
______________________ WORK: ____________________ CELL: ____________________
GENDER:  
MALE: _____ FEMALE: _____
RACE:  
WHITE:____ BLACK: ____ HISPANIC: ____ OTHER: __________________
MARITAL STATUS:  
SINGLE:____ MARRIED: ____ DIVORCED: ____ WIDOWED: ____
EMPLOYED:  
YES:____ NO:____ YEARS EMPLOYED: _____ EMPLOYER: _________________
 
MEDICAL INSURANCE INFORMATION:  
DO YOU HAVE MEDICAIDE:  
YES:____ NO:____  
DO YOU HAVE MEDICARE:  
YES:____ NO:____ MEDICARE #: ________________________________
OTHER MEDICAL INSURANCE:  
YES:____ NO:____ INSURANCE CO: ______________________________
 
  INSURANCE #: _______________________________
MEDICAL DOCTOR OUTSIDE CLINIC:  
YES:____ NO:____ NAME OF DOCTOR: ____________________________
 
EMERGENCY CONTACT INFORMATION:  
NAME:  
_____________________ RELATIONSHIP: ________________ PHONE: ______________
 
HOUSEHOLD INFORMATION (LIST ALL THE PEOPLE THAT LIVE IN YOUR HOUSEHOLD):  
SPOUSE NAME :  
______________________ BIRTHDATE: ______________ SS#: _________________
       
NAME
AGE
RELATIONSHIP
     
     
     
     
     
     
     
     
     
     

 

 

 

PAGE 2
NAME LAST:  
______________________ FIRST: ____________________ MIDDLE: ____________________
HOUSEHOLD ASSETS:
CHECKING ACCOUNT:  
YES:____ NO:____ WHERE: _____________________ BALANCE: __________
SAVINGS ACCOUNT:  
YES:____ NO:____ WHERE: _____________________ BALANCE: __________
RETIREMENT ACCOUNT:  
YES:____ NO:____ WHERE: _____________________ BALANCE: __________
DO YOU OWN YOUR HOME:  
YES:____ NO:____ TAX VALUE: _____________________
DO YOU OWN LAND:  
YES:____ NO:____ TAX VALUE: _____________________
DO YOU OWN OTHER PROPERTY:  
YES:____ NO:____ TAX VALUE: _____________________
WHAT VEHICLES ARE IN HOUSEHOLD:  
YEAR/MODEL: 
_____________________________________________
YEAR/MODEL: 
_____________________________________________
YEAR/MODEL: 
_____________________________________________
YEAR/MODEL: 
_____________________________________________
 
DID YOU FILE INCOME TAXES LAST YEAR:  
YES:____ NO:____ IF YES, MUST BRING IN INCOME TAX RETURN
HOUSEHOLD MONTHLY INCOME: (GROSS INCOME)
 
INCOME SOURCE
PATIENT
OTHER HOUSEHOLD MEMBERS
SALARY/WAGES FULL TIME/PART TIME
 
SELF EMPLOYMENT (1040 SCHEDULE C)    
ODD JOBS    
RENTAL PROPERTY    
UNEMPLOYMENT INSURANCE    
SOCIAL SECURITY RETIREMENT/DISABILITY    
SUPPLEMENTAL SECURITY INCOME (SSI)    
RETIREMENT/PENSION/ANNUITY    
FOOD STAMPS    
CHILD SUPPORT    
OTHER SOURCES    
TOTAL SOURCES OF INCOME:
   GRAND TOTAL INCOME:

IF ZERO INCOME - MUST COMPLETE ZERO INCOME FORM

 
 

 

 

 

 

 

 

 

PAGE 3

NAME LAST:  
______________________ FIRST: ____________________ MIDDLE: ____________________
HOUSEHOLD MONTHLY EXPENSES: (MUST BRING IN PROOF OF EXPENSES)
   
EXPENSE
AMOUNT
MORTGAGE
RENT  
LOT RENT  
HOME EQUITY LOAN  
HOMEOWNER'S / RENTERS / INSURANCE  
UTILITIES  
TELEPHONE  
FOOD  
LIFE INSURANCE  
MEDICARE / SUPPLEMENTAL INSURANCE  
HEALTH INSURANCE  
CAR PAYMENT  
CAR INSURANCE  
TITHES / CHARITABLE GIVING  
TOTAL EXPENSES:
  
         
                                         
 
MONTHLY MEDICAL EXPENSES:
DOCTOR BILLS PAID MONTHLY:  
$_____________________________
HOSPITAL BILLS PAID MONTHLY:  
$_____________________________
SUBTOTAL: 
$_____________________________
OUTSIDE MEDICATIONS PURCHASED BY PATIENT: 
 
MEDICATION
AMOUNT
MEDICATION
AMOUNT
       
       
       
       
       
       
       
       
 
                                         

 

PAGE 4

NAME LAST:  
______________________ FIRST: ____________________ MIDDLE: ____________________

I HAVE COMPLETED THIS FORM AND STATE THAT ALL THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND ABILITY. I AUTHORIZE BROAD STREET CLINIC FOUNDATION, INC. TO MAKE ALL NECESSARY INQUIRIES TO VERIFY THE INFORMATION IN THIS STATEMENT, INCLUDING A CREDIT REPORT UTILIZING A CREDIT REPORTING AGENCY OF YOUR CHOICE. I UNDERSTAND THAT IF IT IS DISCOVERED THAT I HAVE NOT BEEN TRUTHFUL THAT I WILL LOOSE THE PRIVILEGE OF SERVICES AT BSCF.

 
SIGNATURE:
PATIENT: __________________________________  
DATE: __________________________
SIGNATURE:
SPOUSE: __________________________________  
DATE: __________________________
 


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NOTE:
PLEASE MAKE SURE THAT YOU HAVE COMPLETELY FILLED OUT ALL THE INFORMATION ON THE APPLICATION AND HAVE PROVIDED THE FINANICAL DOCUMENTATION FOR YOUR SITUATION.

IF THE APPLICATION IS INCOMPLETE OR MISSING FINANCIAL DOCUMENTATION, YOUR APPLICATION WILL NOT BE ACCEPTED.