Get Catholic Health Initiatives Financial Assistance Application Form (page 1 Of 4)

Filling out the Catholic Health Initiatives Financial Assistance Application Form is an essential step in seeking financial support for medical expenses. This guide offers clear, step-by-step instructions to help users navigate the first page of the application form with ease.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editing area.
2. Enter the patient’s name, social security number, date of birth, and account number if it is known. Ensure accuracy in these fields to avoid delays.
3. Input the guarantor’s name, their relationship to the patient, date of birth, and their social security number. If the guarantor is the same as the patient, simply write 'Same' in this field.
4. Fill in the guarantor’s address, home phone number, and the length of residence at this address.
5. Provide the previous address if the guarantor has lived at their current address for less than two years. Additionally, indicate their marital status and the number of dependents in the household. If there are no dependents, mark ‘-0-’.
6. Respond to the question regarding application for Medicaid or any other state or county assistance. If the answer is Yes, do not continue with the form; instead, reach out to a financial counselor for assistance.
7. List the names and ages of any dependents living in the household.
8. Complete the employer information for the guarantor or patient, including the employer's name, address, job title, length of employment, business telephone number, hourly or salary rate, and monthly income (both gross and net). If there is no employment, explain how expenses are being handled.
9. Provide details of the guarantor/patient's previous employer, including similar information as requested in the previous step.
10. Fill in the spouse's employer information in the same manner. If the spouse is unemployed, note 'N/A'.
11. Indicate any other sources of income, such as child support or social security, and total the family monthly income, as well as the income for the last 12 months.
12. List any other assets owned, such as stocks, bonds, property, or businesses. Attach additional pages if necessary.
13. Answer whether you have filed for bankruptcy and provide details if applicable.
14. Complete the homeowner information, noting the approximate value, balance on loan, and years left on the loan. If not a homeowner, mark 'No'.
15. Provide details regarding any bank accounts, including bank names and average balances for checking and savings.
16. After completing all sections, review the form to ensure no fields are left blank. Save changes, download, print, or share the completed form as needed.

Take the next step towards obtaining financial assistance by completing your application online today.