COMPASSIONATE CARE

You may be eligible to receive discounted care: Complete the application to help Green Springs determine eligibility for our Compassionate Care Program. By completing and signing, the patient acknowledges that he or she has made a good faith effort to provide accurate information requested in the application to assist Green Springs Medical in determining eligibility for financial assistance.

Name__________________________________ Email________________________ DOB______

Address__________________________________________________ Phone # ______________

Rent or Own? _________ Monthly income ____________ Household size __________________

Are you employed _______Where do you work? _______________________________________

Do you receive/amount SSI___________ Disability __________ Other benefits_____________

What is your diagnosis? ___________________________________________________________

______________________________________________________________________________

What symptoms do you experience? ________________________________________________

______________________________________________________________________________

What medications do you take? ____________________________________________________

______________________________________________________________________________

What is your level of pain on scale of 1-10? ___________________________________________

Please explain why you are requesting assistance______________________________________

______________________________________________________________________________

Any other information you would like to include? ______________________________________

______________________________________________________________________________

Signature_______________________________________________Date___________________