Get Kaiser Mfa Program Application 2020

Completing the Kaiser Medical Financial Assistance Program (MFAP) application online can seem daunting, but this guide will provide clear and supportive instructions to help you navigate each section. By following these steps, you can ensure that your application is filled out accurately and submitted successfully.

Follow the steps to complete your application effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editing interface.
2. Begin by filling out the applicant section. Provide your medical record number, phone number, social security number, date of birth, and your name. Ensure all required fields are accurately completed.
3. Input your address including city, state, and ZIP code. Select your marital status from the provided options.
4. Indicate the size of your household, counting yourself, your spouse or partner, dependents, and any other household members.
5. If applicable, provide details about your spouse or domestic partner including their name, date of birth, medical record number, and social security number.
6. List out all household members requiring financial assistance, completing the necessary fields for each individual listed.
7. Specify the financial assistance you are requesting, whether for an outstanding balance or future services. Clearly outline any other needs.
8. In Section A, detail your current monthly gross income, including all sources of income received by your household members. Provide full disclosures as required.
9. Complete Section B if you have any unusually high medical costs. List your out-of-pocket expenses paid over the last year and attach any necessary receipts.
10. Fill out Section C regarding Medicaid/Quest screening if you do not currently have coverage. Indicate your citizenship status and answer related questions.
11. Complete Section D if you are a Medicare Part D beneficiary applying for the low-income subsidy.
12. If necessary, fill out Section E regarding missing income documentation, providing any required explanations.
13. Finalize your application by signing the financial agreement and credit report screening authorization. Make certain all signatures are provided.
14. After you have filled out the application completely, you may choose to save your changes, download, print, or share the completed form.

Ensure your financial assistance application is completed accurately by following these steps, and submit your documents online today.