Follow the steps to complete your application with ease.

1. Press the ‘Get Form’ button to access the Via Christi Financial Assistance application and open it for editing.
2. Begin by entering the patient's information in the designated fields, including their last name, first name, middle initial, social security number, and date of birth. Fill out their street address, city, state, and zip code, as well as the mailing address if it differs.
3. Indicate the patient's gender and language preferences by checking the appropriate boxes. Also, provide the home phone number and work phone number.
4. For the person responsible for paying the bill, fill in their last name, first name, middle initial, relationship to the patient, and insurance details, including the insurance company and social security number.
5. Answer questions regarding the relationship of any physician to the patient and list all household members, including their names, relationships to the patient, dates of birth, and social security numbers. Use additional sheets if necessary.
6. Specify whether the application is for future or past services and provide details about where the services were performed. Also, indicate if the services are related to any workers’ compensation or motor vehicle accident claims.
7. Check any applicable boxes concerning household members' statuses, such as pregnancy, crime victim status, disability, citizenship, and COBRA eligibility.
8. Complete the monthly household income section by providing details for each person in the household, including their name, employer, hours worked, and monthly income from various sources.
9. Indicate if anyone in the household holds any financial accounts or assets by checking appropriate boxes and providing values where asked.
10. Review the authorization sections carefully, making sure to grant necessary permissions for information exchange, and provide your signature and the date of signing.
11. Lastly, save your changes to the document and consider downloading, printing, or sharing your completed form as needed.

Start filling out your financial assistance application online today to ensure you receive the support you need.