Follow the steps to complete your application online.

1. Click ‘Get Form’ button to access the financial assistance application and open it in your preferred document editor.
2. Begin by entering the patient's information in the designated fields. Provide the last name, first name, and middle initial, followed by the street address, city, state, and zip code. Include the home and work phone numbers, social security number, and date of birth. Indicate the marital status by selecting one of the options provided.
3. In the section for the person responsible for paying the bill, input their last name, first name, and middle initial. Specify their relationship to the patient and, if their address is different from the patient's, include it, along with the respective phone numbers and insurance company name.
4. List all individuals living in the household, including the applicant. Provide names, social security numbers, relationships to the patient, and dates of birth. If needed, use an additional sheet to document more people.
5. Indicate whether this application is for future or past services by selecting the appropriate option.
6. If any member of your household has applied for NH Healthy Kids or Medicaid, provide the date of application and the current status.
7. Answer if anyone in your household is pregnant, has served in the military, or has filed a workers' compensation or motor vehicle accident claim, including necessary details as prompted.
8. Identify if anyone in your household is eligible for Social Security benefits and specify who.
9. Indicate whether anyone is covered by health insurance or a health savings account, and provide the names of those individuals, if applicable.
10. Answer if anyone else claims you on their income tax return, and specify who.
11. Complete the household information section by listing household members, their names, employers, and monthly income from various sources including employment, investments, and public assistance. Document checking and savings account balances.
12. Detail household expenses such as rent or mortgage payments, property taxes, utilities, insurance, and healthcare costs. Include all pertinent financial obligations.
13. Review the assignment of rights section carefully, ensuring all adult household members sign the application. This acknowledges understanding of the application process and confirms the accuracy of the information provided.
14. After filling out all required sections, save your changes. You can choose to download, print, or share the completed form as needed.

Complete your Wentworth Douglass Financial Assistance application online today to secure financial support for your medical needs.