Rex Assist Form – Fill Out and Use This PDF

“Rex Assist” Application

Patient Financial Services

4420 Lake Boone Trail

Raleigh, NC 27607

Toll-Free Rex Assist Help Line (866) 687-7674

Fax Number (919) 784-1697

IMPORTANT: To be considered for Charity Care for medically necessary services, this confidential application must be completed. To be considered complete, the following must be attached. IF ALL REQUIRED DOCUMENTATION IS NOT

RECEIVED, REVIEW OF APPLICATION WILL BE DELAYED. ORIGINALS WILL NOT BE RETURNED

•Most recent Federal Income tax return ( All pages required) for patient and spouse (if applicable)

•Last 6 weeks’ pay stubs OR documents of unemployment from the NC Employment Security Commission OR Social Security Statement for patient and spouse OR if you have no household income, a signed statement of support from the person who meets your daily financial needs such as housing, food, and clothing OR Full-time Student status document

•Last 3 months’ (all pages) checking/savings/investment bank statements for patient and spouse – statement format

•Proof of Medicaid eligibility (if applicable)

•If recently unemployed, are you eligible for Cobra? Yes / No - Cobra Name and Address__________________________

I. PATIENT INFORMATION

Patient Name: _______________________________ Rex Hospital Patient Account #: _____________ Marital Status: ______ U S Citizen Y__N___

VISA Y__ N___ Social Security #: ________--_________--____________ Date of Birth: _____/______/______Age ______ Gender M F

II. GUARANTOR INFORMATION (Person legally responsible for bill)

	|	|		|	|		-	-	|
		Last Name	First Name		M.I.		Social Security #
	|	|			| (		)		|
		Rex Hospital Account Number	Relationship to Patient		Area Code- Phone Number
	|		|	|	|		|		|
		Address	City		State		Zip	County
	|				|	(	)		|
		Employer			Phone Number
				 Spouse
	|	|	|	 Parent |					|
		Patient’s Legal Spouse OR Parent if Patient is a Minor	Spouse/Parent Medical Record #		Spouse/Parent Social Security Number
	|				|	(	)		|
		Spouse/Parent Employer				Phone Number

III. OTHER ELIGIBLE DEPENDENTS/SPOUSE/PARENT IF PATIENT IS A MINOR or Full-time student – Total Number in

Household________			Rex Healthcare	Relationship
First Name		Last Name	Medical Record #	to Guarantor or Patient	Date of Birth

IV. OTHER FINANCIAL INFORMATION

Bank(s) Name(s): _________________________________________________________________________________________  Checking  Savings

Total of all family’s checking account balances: $ _______________________ Total of all family’s savings account balance: $ ______________________

Real estate owned other than primary residence: Amount Owed on Mortgage: $_________ Tax Value: $ __________ County/State:_________________

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DOC REVISED 8/29/2012