Get Peacehealth Bridge Program

This guide provides comprehensive instructions on completing the Peacehealth Bridge Program application online, ensuring that users can easily navigate each section of the form. By following these steps, you can efficiently submit your application for assistance.

Follow the steps to fill out your application accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the 'Office Use Only' section, ensuring to provide your patient names, medical record numbers, and the estimated amount owed.
3. In Section A, enter the guarantor name as it appears on the bill, along with their home address, including street, city, state, and zip code. If the mailing address differs, include that as well, along with the home and work phone numbers.
4. Proceed to Section B by listing all individuals living in your household, specifying their relationship to the guarantor, names, dates of birth, citizenship status, social security numbers (not for reporting purposes), and employment status.
5. In Section C, provide monthly income information. Attach copies of the most recent tax returns and the last three months of pay stubs for all household members. Include wages for each wage earner, other sources of income, and provide supporting documentation where necessary.
6. In Section D, detail all assets, including market values and balances owed. Make sure to attach supporting documentation to validate the information provided.
7. In Section E, list all monthly living expenses for all household members, specifying amounts for rent or mortgage, utilities, food, transportation, and other expenses. Include your portion of shared expenses.
8. Section F requires you to list any other creditors, including bank loans, credit cards, personal loans, and medical bills, along with their respective monthly payments and balances.
9. In Section G, include any additional information that may assist in determining your eligibility for assistance.
10. Use Section H for any extra space needed to provide additional details. Finally, certify the accuracy of the information provided by signing and dating the application.
11. After completing the form, you can save your changes, download a copy, print it for your records, or share it as needed.

Take the first step towards assistance by filling out your Peacehealth Bridge Program application online today.