Get Application For Financial Assistance - Centracare Health System

Completing the Application For Financial Assistance from CentraCare Health System is a crucial step for those needing financial support for medical services. This guide provides clear and supportive instructions to help users fill out the form accurately and efficiently.

Follow the steps to complete the application with ease.

1. Press the 'Get Form' button to access and open the Application For Financial Assistance in your preferred online editor.
2. Begin by entering the patient’s name in the designated fields for first, middle, and last names.
3. Provide the complete address, including street number, city, state, and zip code.
4. Input the patient’s home and cell phone numbers in the appropriate fields.
5. Fill in the date of birth for the patient as requested on the form.
6. Next, enter the employer's name and the occupation of the patient, including the date of hire and employer's phone number.
7. If applicable, complete the spouse's information, including their name, occupation, employer, date of hire, and employer's phone number.
8. Indicate whether you filed taxes last year, selecting yes or no.
9. List all sources of income for both the patient and spouse, detailing monthly wages, social security, unemployment compensation, etc.
10. Provide information about dependents, including their names, relationships, and dates of birth.
11. Review the completed information to ensure accuracy, then affirm your understanding by signing as the guarantor and spouse where indicated.
12. Once all fields are filled out, save the changes, download a copy, print if necessary, and share the completed form as directed.

Complete your application for financial assistance online today for timely support.