Get Application Of Financial Aid. - Adena Health System - Adena

Filling out the Application of Financial Aid can seem daunting, but it is a crucial step to accessing financial support for healthcare services. This guide will provide clear and thorough instructions on how to accurately complete this application.

Follow the steps to successfully complete your financial aid application.

1. Click ‘Get Form’ button to obtain the application and open it in the editor.
2. Begin by entering the patient name in the appropriate fields: Last, First, and Middle. If the applicant is not the patient, fill in the applicant's name in the designated area.
3. Provide the address details including street, city, state, and zip code.
4. Enter the social security number of the patient. Then, input the date(s) of hospital service where prompted.
5. You will see several questions regarding residency and insurance status. Answer the questions about voluntary residence in Ohio, Medicaid status, and health insurance. Be ready to provide your Medicaid recipient number if applicable.
6. Fill in details of immediate family members living with the patient, including their name, age, and relationship to the patient.
7. If you reported zero income, please provide a brief explanation. Otherwise, indicate your income for the three months and twelve months prior to hospital service.
8. Supply proof of income by attaching relevant documents such as pay stubs or benefit checks, reflecting three months of income before the date of service.
9. Document your monthly expenses by listing creditors, monthly payments, and outstanding balances in the respective categories.
10. Answer the questions regarding bank accounts and assets, providing their current values where necessary.
11. Finally, sign and date the application to attest to the truthfulness of the information provided. If applicable, an authorized representative may also sign.
12. Once completed, you can save any changes, download or print the form for your records, or share it as needed.

Start your application for financial aid online today to ensure you receive the assistance you need.