Get Financial Assistance Application (english) - Gundersen Health System

This guide aims to assist users in completing the Financial Assistance Application for Gundersen Health System effectively and accurately. By following the outlined steps, users can ensure their application is properly filled out to receive the assistance they need.

Follow the steps to successfully complete the application online.

1. Click ‘Get Form’ button to obtain the Financial Assistance Application and open it for editing.
2. Begin filling out the personal information section. Input your last name, first name, medical record number, and hospital guarantor number as required.
3. Review the checklist provided in the application. Confirm whether you filed taxes by selecting 'Yes' or 'No.' If you answered 'Yes', ensure you include a complete copy of your Federal Tax Returns.
4. Gather and attach the necessary documentation, including pay stubs, medical assistance application, explanation of your financial situation, mortgage statements, bank statements, and any relevant verifications.
5. Complete the applicant and spouse information, including names, dates of birth, addresses, Social Security numbers, and contact information.
6. List all dependents living with you, including their names, ages, and relationships to you.
7. Fill out the employment information section for both the primary applicant and spouse, detailing employers, hire dates, occupations, and gross monthly salaries.
8. Report any additional sources of income for both the primary and secondary applicants, providing written verification of this income for the past 30 days if necessary.
9. Complete the property and assets sections. Disclose your residence status, mortgage details, vehicle information, and any relevant financial assets like checking or savings balances.
10. Certify that all information provided is true and correct. Sign and date the application form as the applicant and have your spouse sign if applicable.
11. Once all information is completed, save changes, and consider downloading, printing, or sharing the form as required.

Complete your Financial Assistance Application online today to ensure you receive the support you need.