Follow the steps to complete the form successfully

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering your account number in the designated field at the top of the form.
3. In the 'Patient Name' section, input the full name of the patient as it appears on official documents.
4. Indicate your Social Security Number in the provided field to help verify eligibility for assistance.
5. Fill in the 'Date of Birth' to confirm the patient's age and eligibility.
6. If the patient is a minor, provide the parent's name and their Social Security Number in the respective fields.
7. Complete the 'Patient's Address' section with the current address to ensure proper communication.
8. Answer the questions regarding disability status and blindness by selecting 'Yes' or 'No' in the appropriate fields.
9. Indicate the number of children under the age of 18 and provide the total family size.
10. State your last 12 months annual household income in the dollar amount field, ensuring accuracy.
11. Input your home phone number along with an optional cell telephone number for further communication.
12. Attach proof of income, such as a 1040 tax return if debts exceed $20,000, and be prepared to provide additional documentation if requested.
13. Carefully read the certification statement at the end of the form and add your signature, along with the date, confirming the information provided is accurate.
14. Finally, review all the information entered for accuracy, then save changes, and proceed to download, print, or share the completed form as needed.

Take the next step and complete the Adventist Midwest Health Financial Assistance Application Form online today.