hospital-texasinstituteforsurgery.docVIP

日期?/ Date：__________ 担保人姓名?/ Guarantor Name： _______________________ 患者姓名?/ Patient Name： _______________________________ 医疗服务日期?/ Date of Service：_____________ 医院账号?/ Hospital Account #____________________________ 病历号?/ Medical Record # _____________ Texas Health Center for Diagnostics Surgery Plano Texas Health Harris Methodist Hospital Southlake Texas Health Presbyterian Hospital Flower Mound Texas Health Presbyterian Hospital Rockwall Texas Institute for Surgery at Presbyterian Hospital of Dallas 尊敬的患者?/ Dear Patient： 所附为德克萨斯州卫生资源财政援助申请表。完成本申请会使我们能够在支付医院账单时提交您的账户，考虑是否可获得财政援助。 只能用于支付您的医院费用。?/ Attached you will find the Texas Health Resources Financial Assistance Application. Completion of this application will enable us to present your account for consideration of financial assistance for your hospital bill(s). This is for your hospital charges only. 我们知道您享有隐私权。 因此，除了验证用途外，您申请中所包含的信息将被视为机密信息。 只有在需要知道的情况下才在德克萨斯州卫生资源机构分享这些信息。?/ We understand your desire for privacy. Accordingly, except for verification purposes, the information included in your application will be treated as confidential information. It will only be shared within Texas Health Resources on a need to know basis. 请完成申请表的各项内容。 如果您需要额外空间进行说明，请使用申请表的背面。?/ Please complete each item on the application. If you need additional space for any explanations, please utilize the back of the application. 请提供您当月和前两个月的工资单复印件和/或任何其他形式的家庭收入证明。 如果您没有收到支票存根，请提供显示您每月存款的银行对账单复印件。 如果是自雇人员，请提供您最近提交的个人所得税纳税申报表复印件和当期损益报表。 未能提供所要求的文件可能会导致拒绝考虑提供财政援助。?/ Please provide copies of your current month and two prior months pay stubs and/or proof of any other form of income for the household. If you do not receive check stubs, please provide copies of your bank statements showing your monthly deposits. If self-employed, please provide a copy of your most recently filed personal i