Get Geisinger Health Plan Financial Statement Application

This guide provides clear and comprehensive instructions on how to fill out the Geisinger Health Plan Financial Statement Application online. Completing this financial statement is an important step toward potentially receiving assistance with medical bills based on your financial situation.

Follow the steps to complete your financial statement application

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Begin by entering the patient name along with their medical record number at the designated fields.
3. Fill in the guarantor's name and their address, including city, state, and ZIP code. Provide an accurate contact number and list the total number of people living in the household.
4. Enter the date of birth of the applicant, along with their social security number and current street address. If applicable, include the name and social security number of the spouse.
5. List the names, dates of birth, and medical record numbers of any other individuals included in this application.
6. Indicate the reason for applying for financial assistance, such as an outstanding balance, and detail any future services expected and their associated costs.
7. Complete the household income section by entering the gross yearly income for the applicant, spouse, and any additional household members. Include all forms of income.
8. Provide information about household assets, including bank account balances and property owned or rented.
9. Fill out the monthly expenses section accurately, listing all recurring costs like mortgage, rent, utilities, and health insurance.
10. Review the financial assistance checklist to ensure all sections are completed and that you have attached the necessary supporting documents.
11. Finally, sign and date the application, certifying the truthfulness of the information provided.
12. Once all information is filled out properly, you may save the changes, download, print, or share the completed form as needed.

Take the necessary steps to complete your Geisinger Health Plan Financial Statement Application online today.