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Get Intermountain Financial Assistance
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Open form follow the instructions
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How to fill out the Intermountain Financial Assistance online
This guide provides clear and supportive instructions for completing the Intermountain Financial Assistance form online. By following these steps, you can ensure all necessary information is accurately submitted to receive assistance.
Follow the steps to complete your financial assistance application.
- Click ‘Get Form’ button to obtain the financial assistance application and open it for editing.
- Begin by entering the patient's name, birth date, social security number, and relationship to the responsible party. Provide the necessary contact information, including home and cell phone numbers.
- Fill in the address section with your current residence information, including city, state, and zip code. Specify how long you have lived at this address.
- In the 'Additional Household Members' section, list the names, birth dates, and relationships of other individuals living in the household.
- Provide the total household monthly income by detailing each source, such as employment income, pension, child support, and any additional income. Ensure the amounts are accurate.
- Complete the assets section by estimating balances for cash, savings accounts, checking accounts, stocks, and retirement accounts.
- Document any outstanding medical expenses you may have by listing the account number, name of the provider, and balance due.
- Answer the questions regarding insurance, Medicaid, and any other financial assistance. Indicate 'Yes' or 'No' where applicable.
- If you have any additional information regarding your financial situation, provide details in the additional comments section.
- Review the information entered for accuracy, sign the form, and date it before submitting. Ensure that all required documentation is attached.
- Once completed, you can save changes, download the form, print it, or share it as needed.
Complete your financial assistance application online today to access vital support.
Financial hardship assistance refers to support provided to individuals facing difficulties meeting their financial obligations. Programs offering Intermountain Financial Assistance aim to ease this burden by providing temporary relief. This assistance can cover essential expenses such as housing, utilities, and healthcare.
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