Get Ahn Financial Assistance

This guide provides clear and supportive instructions for individuals seeking to complete the Ahn Financial Assistance Application online. Follow these steps to ensure that your application is filled out correctly and submitted efficiently.

Follow the steps to fill out the Ahn Financial Assistance Application.

1. Click ‘Get Form’ button to obtain the Ahn Financial Assistance Application and open it for editing.
2. Begin by entering the patient’s name, birthdate, and social security number in the designated fields. Ensure all names are spelled correctly.
3. Provide the home address of the patient, including the street number, apartment number if applicable, city, state, and zip code.
4. Enter daytime and alternate phone numbers. This information ensures that the AHN can contact the applicant if needed.
5. Fill out the employer’s name and phone number for the patient or guarantor in the relevant sections.
6. Indicate the marital status of the patient by selecting one of the options: married, divorced, separated, widowed, or single.
7. Complete the section for the spouse or guarantor name, specifying their relationship to the patient.
8. List all household members and their relationship to the patient as well as their ages. Include all members claimed on IRS Form 1040.
9. Indicate the home ownership status: whether the patient or guarantor owns, rents, or has no home. If applicable, provide assessed value and mortgage details.
10. List details for each motor vehicle owned or leased, including make, model, and year.
11. Provide information about bank accounts, attaching the required two months of statements for each account listed.
12. Detail personal investments by listing their types and current values, ensuring that you attach the necessary statements.
13. Calculate total household monthly income, detailing each source of income and providing proof of each as specified.
14. List the household monthly expenses in the specified areas, ensuring to be accurate as this information is crucial for evaluation.
15. Answer the application questions regarding prior Medical Assistance applications and health insurance status.
16. Sign the form to attest that all information is accurate and understand the implications of providing false information.
17. Finally, save changes, download, print, or share the completed application as needed before submitting it to the appropriate address.

Complete your Ahn Financial Assistance Application online today to receive the support you may need.