Financial Assistance Application   Personal Information First Name    Last Name    Social Security # Phone Number Email Address Address City, State ZIP , AK AL AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS NB NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Account# Amount Account# Amount Account# Amount # of family members in the home  Employer    Income Patient's Gross Income Previous Year Last 3 Months Other Family Income Previous Year Last 3 Months Total Family Income Previous Year Last 3 Months   Assets Savings / Checking  Stocks / Bonds  Additional Vehicle  Other Real Estate  I certify that the above information is true and accurate to the best of my knowledge. Further, I have exhausted all efforts to obtain coverage from all federal, state and local programs, such as Medicaid, Vocational Rehab, etc. I understand this application is made so the hospital can dertermine my eligibility for uncompensated services. Catawba Valley Medical Center reserves the right to reverse the uncompensated services decision if the information provided is found to be false. I agree to allow Catawba Valley Medical Center to access my credit history. For more information, to discuss your application or to set up an appointment, please contact CVMC Business Services by phone at 828-326-3393 or by e-mail at [email protected].