Demographic Information
Correct Mailing Address for Billing Statements:
Income
Assest
Bank Accounts
List all current bank accounts (Including but not limited to checking, savings, CD’s, Money Markets, etc.) 60 months statements required for all accounts, including those closed in the last 60 months.
Investments/Retirement Accounts
List all investment/retirement accounts (including but not limited to stocks, bonds, mutual funds, etc.)
Real Property
Life Insurance
Burial Accounts
Automobiles
Please answer the following questions:
If yes, please supply the date and name or Hospital/Institution:
Documents Needed
- ID Cards: Driver’s License, Social Security Card,
- Proof of Citizenship: Birth Certificate or US Passport
- All Insurance Cards: Medicare, Medicaid/Public Assistance, other Health Insurance
- Current Income Verification for all sources
- Bank Statements: 12 months for all accounts
- Current Investment/Retirement Account Statements
- Copy of Deed, property taxes, appraisal…
- Auto registrations
- Proof of all Health Insurance Premiums
- Proof of all Life Insurance policies
- If Married: marriage license, monthly expenses for spousal allocation, and all of the above for the community spouse