Get Pmg Financial Assistance Application-phone And Address To Ah 021611.doc

Filling out the PMG Financial Assistance Application is an important step for those seeking financial assistance from Provena Medical Group. This guide provides a clear, step-by-step approach to help you complete the application online effectively.

Follow the steps to complete your application successfully.

1. Click the ‘Get Form’ button to obtain the document and open it in your chosen online editor.
2. Start by entering your patient information. Fill in your last name, first name, and middle initial. Ensure this information is accurate, as it is vital for identification.
3. Next, provide the applicant information. If the patient is a minor or a full-time student, list the parent or guardian's details in this section. Include their last name, first name, middle initial, street address, city, state, and zip code.
4. Fill out the co-applicant information if applicable. Similar to step three, provide details for a spouse or parent, including their relationship to the patient, employment information, and social security number.
5. In the income information section, list all sources of income, including employment, social security, and any other relevant income. Be thorough and include all applicable amounts to ensure accurate assessment.
6. If applicable, complete the unemployment section by providing a Room and Board Statement or a supporting letter if there is no monthly income.
7. Add any additional comments or information you feel necessary for the application review.
8. Finally, read the declaration carefully and sign where indicated. Ensure both the applicant and co-applicant sign the form, as this confirms the accuracy of the information provided.
9. After completing the application, retrieve the required supporting documents, such as the Federal Income Tax Return or paycheck stubs, and ensure they are included with your submission.
10. Once filled out, save your changes, download the application for your records, and print a copy if needed. Finally, submit the completed application and attached documents to the specified address.

Take action now and complete the PMG Financial Assistance Application online for better financial support.