Get Catholic Health Initiatives Financial Assistance Application Form

Filling out the Catholic Health Initiatives Financial Assistance Application Form online can be a straightforward process. This guide provides clear step-by-step instructions to ensure you complete the application accurately and submit it successfully.

Follow the steps to complete your application online.

1. Press the ‘Get Form’ button to obtain the form and open it in your editor.
2. In the first section, provide the information for the patient or responsible party, including their social security number, date of birth, and account number if available.
3. Next, fill in the spouse's name and other requested details such as their social security number, date of birth, and mobile phone number.
4. Complete your mailing address, including county of residence, home and mobile phone numbers, city, state, zip code, and length of residence at this address.
5. If you have moved in the last two years, provide your previous address. State your marital status and number of dependents in your household.
6. Answer the questions regarding Medicaid or other state/county assistance. Include the application date and the facility you applied at, and provide your caseworker's name and contact information.
7. List the names, dates of birth, and relationships of all dependents living in your household.
8. Indicate the employment status for yourself and your spouse by circling the correct status such as employed, unemployed, self-employed, etc. Provide details about employment, including job title, length of employment, and employer information.
9. Detail any other income sources you may have, such as child support or unemployment compensation, along with the gross and net monthly income.
10. Disclose any other assets owned, such as stocks or property, and confirm if you have filed for bankruptcy, providing the date and chapter if applicable.
11. Indicate whether you are a homeowner and provide details about the property's value, loan balance, and the years remaining on the loan.
12. Fill in the banking information, including your checking and savings account details along with their average balances.
13. If applicable, describe your current situation if you have no income and attach any supporting documentation as necessary.
14. Provide details for any automobiles you own, including the make, model, year, payment amount, and balance due.
15. Complete the monthly expenses section by listing all your payments for rent/mortgage, utilities, insurance, food, and other expenses. Ensure you total these at the end.
16. Upon completion of all sections, review the entire form for accuracy. Attach any required income verification documents such as pay stubs or tax returns.
17. Save your changes, and if you need to, download, print, or share the form as per your requirements.

Take the first step towards assistance by completing the financial assistance application form online today.