TIOGA MEDICAL CENTER REQUEST FOR DETERMINATION OF ELIGIBILITY FOR UNCOMPENSATED SERVICES

I hereby request Tioga Medical Center make a written determination of my eligibility for uncompensated services at Tioga Medical Center. I understand the information which I submit concerning my annual income and family size is subject to verification by Tioga Medical Center. I also understand that if the information which I submit is determined to be false, such a determination will result in denial of providing services as uncompensated services, and that I will be liable for charges for services provided.

About You

Your Name (*): Your Email (*):
Address: City:
State: Zipcode:
Phone: Cell Phone:
Occupation: Employer:

About Your Income

List Family income for Family From: Total for Last 3 Months Total for Last 12 Months
Wages
Farm or Self Employment
Public Assistance
Social Security
Workers Compensation
Strike Benefits
Alimony
Child Support
Military Family Allotments
Pensions
Income from Dividends, Interest, Rent

About your Family

Name Relationship
1:
2:
3:
4:

Type of Services Required

Please upload one of the following documents:

a. A written release or oral verification of wage information from your employer.
b. Pay stubs showing monthly or yearly earnings.
c. Oral verification from public welfare agencies.
d. Unemployment Compensation or Worker’s Compensation benefit forms.
e. W-2 withholding forms.
f. Income tax returns from prior year, or complete a Form 4506-T to verify you did not file Federal Income tax.

I affirm that the above information is true and correct to the best of my knowledge.

Initial here as your electronic signature:

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