Get Application For Free Care And Partial Free Care ... - Cmmc

This guide provides clear instructions for completing the APPLICATION FOR FREE CARE AND PARTIAL FREE CARE form online. By following these steps, you can ensure that your application is filled out accurately and submitted successfully.

Follow the steps to complete your application efficiently.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Fill in the guarantor's information, which includes the last name, first name, middle initial, address, date of birth, social security number, home phone number, and employer details.
3. Provide details about your spouse, if applicable, by entering their last name, first name, middle initial, date of birth, social security number, employer name, and address.
4. List all dependents by entering their names, ages, and relationships to you, ensuring to complete all fields for each dependent.
5. Outline your sources of income by specifying types such as employment or social security, along with the amount of gross income you have earned over the past thirteen weeks. An estimated yearly income will also be calculated for office use.
6. Document your assets and liabilities by filling out the current balances of checking and savings accounts, as well as any debts or loans you may have.
7. Complete the certification statement by signing and dating the application, ensuring that all provided information is true and complete.
8. Submit the completed application by returning it in the provided envelope or sending it to the specified address for Central Maine Medical Family.

Begin your application process online to access potential free care options today.