Get Request Form - Winthrop University Hospital - Winthrop

Filling out the Request Form for financial assistance at Winthrop University Hospital can seem daunting. This guide will provide you with step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Request Form. This will allow you to open the document and start filling it out.
2. Begin by entering your personal information in the Patient’s Name section. This includes your first, middle, and last name.
3. Next, provide your Social Security number, address including number and street, city, state, and zip code.
4. In the Telephone Number field, enter your phone number, followed by your occupation and employer's name.
5. Fill out your employer's address and telephone number in the designated fields.
6. In the Income section, list the combined income for yourself, spouse, and any other dependents. Fill in the relevant amounts for the past month and the past year under the corresponding categories.
7. In the Family Size section, list the names, ages, and relationships of family members living in your household. Use an additional sheet if necessary.
8. Review the statement affirming that the information provided is true and correct. Sign and date the form.
9. Ensure that all required documents are attached, including IRS Forms W-2 or 1099, current pay stubs, and any other requested proofs of income or resources.
10. Finally, save your changes, and options may include downloading, printing, or sharing the completed form.

Complete your financial assistance application online today.