Get Edward Hospital Financial Assistance Program

This guide provides clear, step-by-step instructions on how to fill out the Edward Hospital Financial Assistance Program form online. By following these instructions, individuals seeking financial assistance for medical care will be equipped with the necessary tools to accurately complete the application.

Follow the steps to complete the application effectively.

1. Click ‘Get Form’ button to obtain the financial assistance application form and open it in the appropriate editor.
2. Begin by providing your personal information in the 'Patient Information' section. Fill in your name, date of birth, social security number (optional), address, city, state, zip code, email address, and telephone number. Indicate whether you were an Illinois resident at the time services were rendered.
3. Next, complete the 'Household Information' section. List the number of persons in your family household and the number of dependents. Be sure to include the ages of all dependents.
4. Proceed to the 'Employment Information' section. Here, provide the name and address of your employer, as well as the telephone number. If applicable, also include similar details for your partner’s employer.
5. In the 'Income' section, itemize various sources of income such as wages, self-employment earnings, Social Security benefits, disability payments, alimony, and any other income over the past three months. Record each source of income and the corresponding amount.
6. Move to the 'Assets' section. Report the total amounts in checking and savings accounts, stocks, certificates of deposit, retirement accounts, and any vehicles or property you own.
7. If applicable, check the criteria that exempt you from filling out the 'Monthly Expenses' section. If not exempt, complete the 'Monthly Expenses' table by listing all relevant expenses, such as housing, utilities, food, transportation, and medical expenses.
8. Finally, review all the provided information for accuracy. Sign and date the certification statement affirming that the information is true and correct to the best of your knowledge.
9. After completing the application, you can save changes, download the form, print, or share it as required. Ensure that all supporting documents are compiled and return the application to the designated address or location.

Complete your application online today to access the Edward Hospital Financial Assistance Program.