Get Financial Application - Bothwell Regional Health Center

Completing the Financial Application for Bothwell Regional Health Center is an essential step in obtaining financial assistance for medical services. This guide provides clear instructions to help you fill out the form accurately and efficiently.

Follow the steps to complete your financial application online.

1. Click ‘Get Form’ button to access the Financial Application and open it for completion.
2. Fill in the 'Date Sent' and 'Date Due' fields. Ensure you note the deadlines for your application submission.
3. Enter the patient’s details, including their name, social security number (SSN), date of birth (DOB), marital status, and contact information.
4. Include the guarantor's details. This may be the spouse or another responsible party. Provide their name, SSN, DOB, and relationship to the patient.
5. Complete the sections on employment. Note the previous employer's name, last date employed, and gross income information for both the patient and the spouse.
6. Specify the household size, detailing the number of adults and children living in the household.
7. Indicate your housing situation by selecting whether you own or rent. Fill out the employer's information and monthly income from different sources, such as wages, social security income, and others.
8. List monthly expenses, categorizing them appropriately (e.g., rent/mortgage, utilities, food, etc.).
9. Detail any outstanding creditor balances, including payments and whether they are current.
10. Calculate your total monthly income and total monthly expenses, then determine the difference.
11. Sign the patient agreement section, confirming that all information is accurate and that you consent to the release of information necessary for processing your application.
12. Prepare and attach any required supplemental documentation as indicated in the application.
13. Once completed, save your changes, download a copy, print it, or share it as needed to submit your application.

Start filling out your Financial Application online today to access the assistance you need.