Jan Patterson - Publicforms

Available Forms

2022 New Patient Medical History Form (Female) Athena New Patient Demographic and Insurance Form New Patient Medical History Form (Male) Application for Sponsorships (For Use with Financial Hardship only)

Application for Sponsorships (For Use with Financial Hardship only)

If you are having or expect to have difficulty with affording care at Gianna of Albany, this application is intended for submission to separate non-profit corporations or churches that may be able to assist you with the cost of your care if sponsorships are available. It may also be used in consideration of reduced fees or payment plans if possible by Gianna of Albany.

First Name *

Last Name *

Date of Birth *

Street Address *

City, State Zipcode *

Home phone

Mobile phone

Medical Insurance?

Yes, but high deductible

Yes

If yes to question above, what insurance do you have and what is your deductible? *

Household size *

Number of persons in your household

Annual income of household *

Reason for requesting a sponsorship or for reduced fees *

Please describe briefly your reasons for requesting a sponsorship or for reduced fees.

Some patients may be eligible to pay for services on a payment plan. Amount per month that you are or will be able to pay towards your balance with Gianna of Albany. *

* Required field