Get Medically Indigent Form

Filling out the Medically Indigent Form online can be a straightforward process when you have a clear understanding of its components. This guide will provide you with step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete the Medically Indigent Form.

1. Click the ‘Get Form’ button to obtain the Medically Indigent Form and access it in your editor.
2. Begin with the completion by customer section. Here, print your name clearly in the designated space. If applicable, provide your spouse's name. Next, include your home and work phone numbers, as well as your service address and mailing address if it differs from your service address.
3. In the certified representative section, a representative will need to print their name, along with the governmental entity or energy assistance program provider they represent. They must confirm that your total income is at or below 150% of the Federal poverty guidelines and that your monthly out-of-pocket medical expenses exceed 20% of your household's gross income. The representative will then sign and date the form.
4. The attending physician must complete their section by providing their name, phone number, and address. They will also need to certify that you or your spouse is unable to perform three or more activities of daily living. This section requires the physician's signature and date.
5. Finally, you, the customer, need to print your name, sign the form, and include the date signed. Ensure that all information is accurate and clearly written.
6. Once the form is completed, you can save your changes, download a copy for your records, print the form, or share it as needed.

Complete your Medically Indigent Form online today to ensure you receive the assistance you need.