Speech-Language-Hearing Clinic Financial Assistance Application

Please answer all questions in each section. If a section does not apply to you, please indicate this on the application by stating "Not Applicable."

Make sure to have your Federal Income Tax form and proof of income document scanned and ready to attach at the bottom of this form.

Patient Information

Patient Name Patient Name First Last
Patient's Date of Birth Patient's Date of Birth / MM / DD YYYY
If more than one child is a patient, please list other child(ren)'s name and date of birth
Household Information
Head of Household Name Head of Household Name First Last
Head of Household Email
Head of Household Phone Head of Household Phone - ### - ### ####
Head of Household Address Head of Household Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Household Size-All members living in the household. "Household" is all persons living with you at the same address. If a living situation is temporary, please advise the clinic coordinator.

Please list name, date of birth and relationship of each household member.
Are you, or a member of your household, affiliated with Oklahoma State University?

Are you, or a member of your household, affiliated with Oklahoma State University? No Yes
If affiliated with OSU, what is your primary classification?

If affiliated with OSU, what is your primary classification? Faculty Staff Student
Name of OSU Affiliate Name of OSU Affiliate First Last
CWID or SSN
Insurance Information
Name of Insurance
Policy Holder Name Policy Holder Name First Last
Policy Holder Date of Birth Policy Holder Date of Birth / MM / DD YYYY
Policy #/Member ID
Group #
Income Information

Please enter information for all sources of income:
Salaries and Wages for Self

Salaries and Wages for Self Weekly Bi-Weekly Monthly Annually Not Applicable/OSU Affiliate Enter Gross Amount Enter Gross Amount

Make sure to enter the Gross Amount if applicable.
Salaries and Wages for Spouse

Salaries and Wages for Spouse Weekly Bi-Weekly Monthly Annually Not Applicable/OSU Affiliate Enter Gross Amount Enter Gross Amount

Make sure to enter the Gross Amount if applicable.
Salaries and Wages-Other

Salaries and Wages-Other Weekly Bi-Weekly Monthly Yearly Not Applicable/OSU Affiliate Enter Gross Amount Enter Gross Amount

Make sure to enter the Gross Amount if applicable.
Workman's Comp (SIIS)

Workman's Comp (SIIS) Weekly Bi-Weekly Monthly Annually Not Applicable/OSU Affiliate Enter Gross Amount Enter Gross Amount

Make sure to enter the Gross Amount if applicable.
Social Security (Self and Spouse)

Social Security (Self and Spouse) Weekly Bi-Weekly Monthly Annually Not Applicable/OSU Affiliate Enter Gross Amount Enter Gross Amount

Make sure to enter the Gross Amount if applicable.
Social Security (Children)

Social Security (Children) Weekly Bi-Weekly Monthly Yearly Not Applicable/OSU Affiliate Enter Gross Amount Enter Gross Amount

Make sure to enter the Gross Amount if applicable.
Child Support/Alimony

Child Support/Alimony Weekly Bi-Weekly Monthly Yearly Not Applicable/OSU Affiliate Enter Gross Amount Enter Gross Amount

Make sure to enter the Gross Amount if applicable.
Military/Veterans Benefits

Military/Veterans Benefits Weekly Bi-Weekly Monthly Yearly Not Applicable/OSU Affiliate Enter Gross Amount Enter Gross Amount

Make sure to enter the Gross Amount if applicable.
Unemployment Benefits

Unemployment Benefits Weekly Bi-Weekly Monthly Yearly Not Applicable/OSU Affiliate Enter Gross Amount Enter Gross Amount

Make sure to enter the Gross Amount if applicable.
For additional circumstances, please elaborate on financial hardship details. Please write in what you think you can pay.
Signature

Please read the following carefully:

I declare that my household's financial status is as listed above. I understand the following:
*Giving false information regarding my household income will be grounds for immediate termination of services from the clinic.
*Any changes in my finances or the number of people in my household must be reported to the OSU Speech-Language-Hearing Clinic and a new application must be completed.
Applicant's Printed Name Applicant's Printed Name First Last
Draw or type your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Upload a File
Please upload federal income tax form and copies of proof of income.

Attach Files

Speech-Language-Hearing Clinic Financial Assistance Application

Speech-Language-Hearing Clinic Financial Assistance Application

Household Information

Insurance Information

Income Information

Signature