Get Georgia Region Medical Financial Assistance Program - Kaiser ... - Kpgagives

This guide provides a clear and supportive walkthrough for completing the GEORGIA REGION Medical Financial Assistance Program application from Kaiser. Whether you are applying for yourself or on behalf of someone else, following these detailed steps will ensure that you properly fill out the form online.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to initiate the process and access the necessary application form.
2. Begin by filling in the patient's name, including the last name, first name, and middle initial. Ensure accuracy for identification purposes.
3. Provide the patient's address details, including any apartment number, city, state, and ZIP code. Check that this information is complete.
4. Enter the patient's date of birth in the specified format. This is essential for age verification.
5. Input the health record number, if available. This information aids in maintaining accurate medical records.
6. Fill in the home phone number, work phone number, and cell/mobile number for the patient. Having multiple contact options is recommended.
7. Provide the name of the patient’s employer, along with the employer’s address and contact information, which is important for income verification.
8. If applicable, enter the spouse’s name and their relevant contact information, including address and phone numbers.
9. List the dependents’ names along with their dates of birth and relationship to the patient. This is necessary for determining financial assistance eligibility.
10. Document the total gross income amount and detail the various sources of income. This section is crucial for assessing financial need.
11. In the remarks section, you may briefly explain any special circumstances or information relevant to your application.
12. Fill in the name of the treating physician or clinician and describe the supplies or services requested, if applicable.
13. In the 'Change in Circumstances' section, explain any recent changes that have led to the need for assistance.
14. Review the certification statement carefully. By signing, you confirm that the information provided is accurate and grant permission for verification as needed.
15. Sign and date the form as the applicant or the applicant's personal representative. Additionally, ensure a witness signature is provided.
16. Finally, attach the required W2 forms and pay stubs for the previous year for both partners, or any other necessary income verification documents.
17. Once all sections are completed, save the changes, then download, print, or share the completed form as needed.

Begin filling out your application online now for the GEORGIA REGION Medical Financial Assistance Program.