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Financial Application Instructions

If you are unable to meet the required payment arrangement on your account due to a permanent or temporary financial situation, you may request a review of your circumstances to determine if you qualify for alternative arrangements. To begin the process, complete the financial statement form available on this web site and submit the following information:

1. A current statement of assets, liabilities and income as requested on the application.

2. Your most recent tax return (to include all copies of applicable forms, schedules and required attachments)

3.  Your most recent pay stub(s) (must show work history for past 4 weeks)

4.  Proof of:   a) Permanent Residency - Any of the following will be accepted:   Mortgage Coupon, Rental Agreement, Visa or Passport, Current Electric Bill, Current Phone Bill  (The required documents showing proof of residency may also be in the spouse's name, but must match the address listed for the patient/guarantor.)

                    b) Disability

                    c) Medicaid Denial

                    d) All sources of household income (Bank statements, child support, alimony, etc)

Upon receipt and review of your application, and all of the required documentation listed above, WakeMed will contact you regarding any alternate payment arrangements that can be made on your account. Until you have received written notification from WakeMed regarding a change in payment arrangements, please continue to make the required payments.

RETURN THE APPLICATION TO:
PFS- Customer Service Unit
P.O. Box 29516
Raleigh, N.C. 27626

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