For Patients & Families

Financial Assistance Application Information

Backus requires some basic information in order to accurately process a financial assistance application. Such questions include household size, household income, and sources of income.  Please see the Financial Assistance Policy and application for more information.

  • To report household size for an adult applicant, please include the patient, the patient’s spouse, and any dependents that meet the Internal Revenue Service (“IRS”) definition of a dependent.
  • To report household size for a minor applicant, please include the patient, the patient’s mother, dependents of the patient’s mother, the patient’s father, and dependents of the patient’s father.  Dependents should meet the definition set forth by the IRS. Individuals should only be counted once when calculating a household size.
  • To accurately report household income for an adult applicant, include the total annual gross income of the patient and the patient’s spouse, and any household dependents who are currently working.
  • To accurately report household income for a minor applicant, include the total annual gross income of the patient, the patient’s mother and the patient’s father or the legal guardian of the patient.

Proof of income or earnings is required with application or the application will not be considered.

To apply please submit the attached Application for Financial Assistance and the following verifications of income information:

  • Most recent Federal tax return and W-2
  • Most recent 3 payroll checks
  • Copies of unemployment checks
  • Copies of any pension, alimony, child support or other sources of income
  • Copies of Social Security earnings, if any
  • Any other pertinent information.

Please allow 3 to 4 weeks for processing time; you will be notified by mail of the outcome of your application.